Provider Demographics
NPI:1679703458
Name:INTERCULTUAL PSYCHIATRIC PROGAM
Entity type:Organization
Organization Name:INTERCULTUAL PSYCHIATRIC PROGAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:QUALIFIED MENTAL HEALTH ASSOCIATE
Authorized Official - Prefix:MRS
Authorized Official - First Name:AMBIKA
Authorized Official - Middle Name:
Authorized Official - Last Name:KAPHLE
Authorized Official - Suffix:
Authorized Official - Credentials:QMHA
Authorized Official - Phone:503-418-5063
Mailing Address - Street 1:3633 SE 35TH PLACE
Mailing Address - Street 2:
Mailing Address - City:PORLTAND
Mailing Address - State:OR
Mailing Address - Zip Code:97202
Mailing Address - Country:US
Mailing Address - Phone:503-418-5063
Mailing Address - Fax:
Practice Address - Street 1:3633 SE 35TH PLACE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97202
Practice Address - Country:US
Practice Address - Phone:503-418-5063
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-15
Last Update Date:2009-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR01301974305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization