Healthcare Provider Details

I. General information

NPI: 1659975944
Provider Name (Legal Business Name): CLACKAMAS COUNSELING CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/26/2020
Last Update Date: 12/03/2021
Certification Date: 12/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5200 MEADOWS RD STE 150
LAKE OSWEGO OR
97035-0066
US

IV. Provider business mailing address

5200 MEADOWS RD STE 150
LAKE OSWEGO OR
97035-0066
US

V. Phone/Fax

Practice location:
  • Phone: 503-351-0463
  • Fax:
Mailing address:
  • Phone: 503-351-0463
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: COLETTE DAWN KELSEY-FIKE
Title or Position: THERAPIST
Credential: LCSW
Phone: 503-477-2428