MEDICARE: SUSAN J KILEY LICSW, LMP, LMT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	LW00006247	WA

General Provider Information

NPI Number	:	1275782591
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUSAN J KILEY LICSW, LMP, LMT

Provider Business Mailing Address
First Line	:	2734 NE BRYCE ST.
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97212
Country	:	US
Telephone Number	:	503-807-6880
Fax Number	:

Provider Business Practice Location Address
First Line	:	2734 NE BRYCE ST
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97212-1638
Country	:	US
Telephone Number	:	503-807-6880
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/10/2008
Last Update Date	:	09/10/2008

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