MEDICARE: KRISTIAN GREGORY KINGSTAD

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

General Provider Information

NPI Number	:	1467232868
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KRISTIAN GREGORY KINGSTAD

Provider Business Mailing Address
First Line	:	11 SW GIBBS ST
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97239-4660
Country	:	US
Telephone Number	:	503-206-8856
Fax Number	:

Provider Business Practice Location Address
First Line	:	11 SW GIBBS ST
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97239-4660
Country	:	US
Telephone Number	:	503-206-8856
Fax Number	:

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

Provider Enumeration Date	:	10/03/2023
Last Update Date	:	10/03/2023

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Directions to “ KRISTIAN GREGORY KINGSTAD ” Practice Location

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