Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 104100000X | Social Worker |
NPI | 1003186636 |
---|---|
Provider Name | Amy Hetlage |
First Address | Portland, OR 97202-3371 |
Second Address | Portland, OR 97202-3371 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 12/01/2012 |
Last Update Date | 12/01/2012 |