Healthcare Provider Details

I. General information

NPI: 1972983096
Provider Name (Legal Business Name): KWABENA SIAKA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2015
Last Update Date: 09/10/2026
Certification Date: 09/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2028 SE MARION ST SUITE 11
PORTLAND OR
97202-7365
US

IV. Provider business mailing address

2225 N LOMBARD ST STE 201
PORTLAND OR
97217-5772
US

V. Phone/Fax

Practice location:
  • Phone: 503-422-6021
  • Fax:
Mailing address:
  • Phone: 971-220-5876
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number21-02-30006
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number18QMHPC00019
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: