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General NPI Number Information
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NPI Number | 1003461740
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Entity Type | Organization
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Legal Business Name | TIFFANY KETTERMANN, LLC
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Dates
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Enumeration Date | 08/08/2019
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Last Update Date | 02/25/2025
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Provider Practice Location Address
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Address Line | 2950 SE STARK ST STE 130
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City | PORTLAND
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State | OR
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Zip | 97214-3082
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Country | US
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Telephone | 971-270-0167
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Fax |
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Provider Business Mailing Address
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Address Line | 2950 SE STARK ST STE 130
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City | PORTLAND
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State | OR
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Zip | 97214-3082
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Country | US
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Telephone | 971-270-0167
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | TIFFANY KETTERMANN
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Credential | LPC, LMHC, CADCI
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Telephone | 971-270-0167
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State |
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