Healthcare Provider Details

I. General information

NPI: 1265213789
Provider Name (Legal Business Name): HANSON ELLIS DAVENPORT KRIEGEL CSWA, MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2023
Last Update Date: 10/31/2023
Certification Date: 10/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2951 NW DIVISION ST STE 165
GRESHAM OR
97030-5295
US

IV. Provider business mailing address

2951 NW DIVISION ST STE 165
GRESHAM OR
97030-5295
US

V. Phone/Fax

Practice location:
  • Phone: 971-220-2496
  • Fax:
Mailing address:
  • Phone: 971-220-2496
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberA14435
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: