MEDICARE: DAVID JOHN KOHLER LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	1706	OR
2	101YA0400X	Addiction (Substance Use Disorder) Counselor	02-03-28	OR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	089784006	OTHER	OR	BC/BS

General Provider Information

NPI Number	:	1164404836
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DAVID JOHN KOHLER LCSW

Provider Business Mailing Address
First Line	:	2415 SE 43RD AVE
Second Line	:	SUITE 100
City	:	PORTLAND
State	:	OR
Zip	:	97206-1600
Country	:	US
Telephone Number	:	503-238-0705
Fax Number	:	503-236-7166

Provider Business Practice Location Address
First Line	:	2415 SE 43RD AVE
Second Line	:	SUITE 100
City	:	PORTLAND
State	:	OR
Zip	:	97206-1600
Country	:	US
Telephone Number	:	503-238-0705
Fax Number	:	503-236-7166

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/17/2005
Last Update Date	:	09/06/2012

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