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General NPI Number Information
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NPI Number | 1902280365
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Entity Type | Individual
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Provider Name | KRISTINA IVY LCSW
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Gender | Female
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Dates
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Enumeration Date | 07/16/2015
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Last Update Date | 02/03/2024
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Provider Practice Location Address
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Address Line | 17727 E BURNSIDE ST
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City | PORTLAND
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State | OR
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Zip | 97233-4803
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Country | US
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Telephone | 503-215-9800
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Fax |
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Provider Business Mailing Address
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Address Line | 2637 N HALLECK ST
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City | PORTLAND
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State | OR
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Zip | 97217-6361
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Country | US
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Telephone | 208-284-3508
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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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 | 084358
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License Number State | NY
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Taxonomy #2
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number |
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License Number State | OR
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Taxonomy #3
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Taxonomy Code | 104100000X
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Taxonomy Name | Social Worker
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License Number |
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License Number State | OR
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