Healthcare Provider Details

I. General information

NPI: 1093939662
Provider Name (Legal Business Name): CAROL ANN MCKINNON LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/12/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8835 SW CANYON LN SUITE 240
PORTLAND OR
97225-3443
US

IV. Provider business mailing address

8835 SW CANYON LN SUITE 240
PORTLAND OR
97225-3443
US

V. Phone/Fax

Practice location:
  • Phone: 503-292-5439
  • Fax: 503-292-4738
Mailing address:
  • Phone: 503-292-5439
  • Fax: 503-292-4738

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number326
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: