Healthcare Provider Details

I. General information

NPI: 1982721403
Provider Name (Legal Business Name): KATHLEEN A. MOUNTS LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/22/2007
Last Update Date: 04/23/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1217 NE BURNSIDE RD SUITE C601
GRESHAM OR
97030-6722
US

IV. Provider business mailing address

2881 SW LILLYBEN PL
GRESHAM OR
97080-9507
US

V. Phone/Fax

Practice location:
  • Phone: 503-674-5902
  • Fax: 503-492-4816
Mailing address:
  • Phone: 503-674-5902
  • Fax: 503-492-4816

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberRC00053123
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberL4040
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: