Healthcare Provider Details

I. General information

NPI: 1487118170
Provider Name (Legal Business Name): CHRISTINA MARIE KUCERA MSW, LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/26/2019
Last Update Date: 12/27/2021
Certification Date: 12/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4827 NE CAMPAIGN ST
PORTLAND OR
97218-1732
US

IV. Provider business mailing address

4827 NE CAMPAIGN ST
PORTLAND OR
97218-1732
US

V. Phone/Fax

Practice location:
  • Phone: 971-212-0589
  • Fax:
Mailing address:
  • Phone: 971-212-0589
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberL5820
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: