=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134428071
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MONTA CLIFTON KNUDSON
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/17/2011
-----------------------------------------------------
Last Update Date | 01/21/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 727 NE 24TH AVE
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97232-2222
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-228-9229
-----------------------------------------------------
Fax | 503-228-9558
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2438 NW FARGO ST
-----------------------------------------------------
City | CAMAS
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98607-9356
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-278-6719
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------