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General NPI Number Information
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NPI Number | 1790095743
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Entity Type | Organization
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Legal Business Name | ANICCA LLC
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Dates
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Enumeration Date | 10/08/2010
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Last Update Date | 10/08/2010
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Provider Practice Location Address
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Address Line | 1020 SW TAYLOR ST STE 685
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City | PORTLAND
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State | OR
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Zip | 97205-2511
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Country | US
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Telephone | 503-421-5904
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Fax |
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Provider Business Mailing Address
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Address Line | 1020 SW TAYLOR ST STE 685
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City | PORTLAND
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State | OR
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Zip | 97205-2511
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Country | US
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Telephone | 503-421-5904
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Fax |
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Authorized Official
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Title or Position | MANAGING MEMBER
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Name | MR. KENNETH L ANDERT
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Credential | LCSW
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Telephone | 503-421-5904
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 1423
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License Number State | OR
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