=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184271967
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LAINE MILLER-KENNINGTON CSWA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/26/2019
-----------------------------------------------------
Last Update Date | 09/19/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9755 SW BARNES RD STE 650
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97225-6657
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-591-9280
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4585 SW 185TH AVE
-----------------------------------------------------
City | ALOHA
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97078-1557
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-591-9280
-----------------------------------------------------
Fax | 503-655-6806
-----------------------------------------------------
=====================================================
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 | A15557
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------