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NPI Code Detail

MEDICARE: LANA JOY SHOTWELL KUBO MA

MEDICARE: LANA JOY SHOTWELL KUBO MA
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
1101YM0800XMental Health Counselor
2101YP2500XProfessional CounselorC2396OR

General Provider Information

NPI Number : 1750431649
Entity Type Code : Individual
Provider Name (Legal Business Name) : LANA JOY SHOTWELL KUBO MA
Provider Business Mailing Address
First Line : 3415 SE POWELL BLVD
Second Line :
City : PORTLAND
State : OR
Zip : 97202-3371
Country : US
Telephone Number : 503-813-7705
Fax Number : 503-205-0188
Provider Business Practice Location Address
First Line : 3415 SE POWELL BLVD
Second Line :
City : PORTLAND
State : OR
Zip : 97202-3371
Country : US
Telephone Number : 503-813-7705
Fax Number : 503-205-0188
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 01/11/2007
Last Update Date : 02/23/2010

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Directions to “ LANA JOY SHOTWELL KUBO MA” Practice Location

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