Provider Demographics
NPI:1679212427
Name:CHAKHTOURA, MARY
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:CHAKHTOURA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2039 E BURNSIDE ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-1649
Mailing Address - Country:US
Mailing Address - Phone:206-397-6815
Mailing Address - Fax:
Practice Address - Street 1:3500 NE MARTIN LUTHER KING JR BLVD STE 200
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97212-2093
Practice Address - Country:US
Practice Address - Phone:503-327-8205
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-31
Last Update Date:2024-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health