Provider Demographics
NPI:1831373844
Name:CANTAL, AMANDA (MA, LPC, CADC I)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:CANTAL
Suffix:
Gender:F
Credentials:MA, LPC, CADC I
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 82819
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97282-0819
Mailing Address - Country:US
Mailing Address - Phone:503-233-5405
Mailing Address - Fax:503-233-2694
Practice Address - Street 1:12636 SE STARK ST
Practice Address - Street 2:PLAZA 125 BUILDING J
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97233-1058
Practice Address - Country:US
Practice Address - Phone:503-253-4600
Practice Address - Fax:503-253-4609
Is Sole Proprietor?:No
Enumeration Date:2007-12-27
Last Update Date:2011-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC2525101YP2500X
OR09-03-07101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR164936Medicaid
ORR0000WDBCHOtherMEDICARE GROUP