=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275782591
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SUSAN J KILEY LICSW, LMP, LMT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/10/2008
-----------------------------------------------------
Last Update Date | 09/10/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2734 NE BRYCE ST
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97212-1638
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-807-6880
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2734 NE BRYCE ST.
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97212
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-807-6880
-----------------------------------------------------
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 | LW00006247
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------