=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174907133
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KRISTINA HOUCK LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/18/2015
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8638 N LOMBARD ST STE 2
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97203-3741
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 971-361-8844
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9221 N LOMBARD ST APT 9
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97203-2174
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-327-4724
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | L4092
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------