1013005792 NPI number — ALAN P KAISER PMHNP, LCSW

Table of content: ALAN P KAISER PMHNP, LCSW (NPI 1013005792)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013005792 NPI number — ALAN P KAISER PMHNP, LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KAISER
Provider First Name:
ALAN
Provider Middle Name:
P
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PMHNP, LCSW
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1013005792
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/03/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3011 SW VESTA ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORTLAND
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97219-8926
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-245-5356
Provider Business Mailing Address Fax Number:
448-407-3498

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1340 SW BERTHA BLVD
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97219-2039
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-245-5356
Provider Business Practice Location Address Fax Number:
503-245-5393
Provider Enumeration Date:
10/10/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  001741 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LP0808X , with the licence number: NP 091007250N6 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 077938 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".




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