Healthcare Provider Details

I. General information

NPI: 1013973668
Provider Name (Legal Business Name): KEVIN MARK SENN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2006
Last Update Date: 01/11/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

707 SW GAINES ST. CDRC
PORTLAND OR
97239-3098
US

IV. Provider business mailing address

707 SW GAINES ST. CDRC
PORTLAND OR
97239-3098
US

V. Phone/Fax

Practice location:
  • Phone: 503-494-1619
  • Fax: 503-494-6868
Mailing address:
  • Phone: 503-494-1619
  • Fax: 503-494-6868

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number183438
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code2080P0006X
TaxonomyDevelopmental - Behavioral Pediatrics Physician
License Number153312
License Number StateOR
# 3
Primary TaxonomyN
Taxonomy Code2080P0008X
TaxonomyPediatric Neurodevelopmental Disabilities Physician
License Number183438
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: