Healthcare Provider Details

I. General information

NPI: 1851451157
Provider Name (Legal Business Name): CASEY KOHL LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/11/2006
Last Update Date: 10/26/2022
Certification Date: 10/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

753 SE MAIN ST # 210
ROSEBURG OR
97470-3984
US

IV. Provider business mailing address

727 SE CASS AVE STE 220
ROSEBURG OR
97470-4953
US

V. Phone/Fax

Practice location:
  • Phone: 541-671-2040
  • Fax:
Mailing address:
  • Phone: 541-671-2040
  • Fax: 775-623-6584

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number3719
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number4957-C
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: