MEDICARE: MS. CHERI SUZZETTE HAVLENA A12950

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	104100000X	Social Worker	CG60497290	WA
2	104100000X	Social Worker	A12950	OR

General Provider Information

NPI Number	:	1558541060
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. CHERI SUZZETTE HAVLENA A12950

Provider Business Mailing Address
First Line	:	2705 E BURNSIDE ST STE 206
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97214-1768
Country	:	US
Telephone Number	:	360-609-6927
Fax Number	:

Provider Business Practice Location Address
First Line	:	2705 E BURNSIDE ST STE 206
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97214-1768
Country	:	US
Telephone Number	:	503-320-7136
Fax Number	:

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

Provider Enumeration Date	:	11/13/2007
Last Update Date	:	07/24/2022

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