Healthcare Provider Details

I. General information

NPI: 1053225839
Provider Name (Legal Business Name): KEVIN OMAR COURTNEY-VERA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/30/2026
Last Update Date: 09/30/2026
Certification Date: 09/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

565 UNION ST NE STE 205
SALEM OR
97301-2418
US

IV. Provider business mailing address

1848 MERIDIAN DR
WOODBURN OR
97071-7735
US

V. Phone/Fax

Practice location:
  • Phone: 503-991-5522
  • Fax:
Mailing address:
  • Phone: 971-353-3025
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: