Healthcare Provider Details

I. General information

NPI: 1134774995
Provider Name (Legal Business Name): KRISTAN CHOW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KRISTAN HOLDING

II. Dates (important events)

Enumeration Date: 08/07/2019
Last Update Date: 09/02/2026
Certification Date: 09/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

510 NE ROBERTS AVE STE 350D
GRESHAM OR
97030-7404
US

IV. Provider business mailing address

16439 SE 287TH AVE
BORING OR
97009-8607
US

V. Phone/Fax

Practice location:
  • Phone: 503-622-8418
  • Fax:
Mailing address:
  • Phone: 503-720-7233
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: