MEDICARE: KALLIE COTHERN

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	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1841726270
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KALLIE COTHERN

Provider Business Mailing Address
First Line	:	7619 N ALBINA AVE
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97217-1307
Country	:	US
Telephone Number	:	503-662-8989
Fax Number	:

Provider Business Practice Location Address
First Line	:	7619 N ALBINA AVE
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97217-1307
Country	:	US
Telephone Number	:	503-662-8989
Fax Number	:

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

Provider Enumeration Date	:	05/04/2017
Last Update Date	:	08/26/2022

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Directions to “ KALLIE COTHERN ” Practice Location

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