Basic Information
| Provider Information | |||||||||
| NPI: | 1134774995 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHOW | ||||||||
| FirstName: | KRISTAN | ||||||||
| MiddleName: | |||||||||
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| OtherLastName: | HOLDING | ||||||||
| OtherFirstName: | KRISTAN | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 11035 NE SANDY BLVD | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972202553 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032584200 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 912 NE KELLY AVE STE 200 | ||||||||
| Address2: | |||||||||
| City: | GRESHAM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970305637 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032584600 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/07/2019 | ||||||||
| LastUpdateDate: | 01/16/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 01/16/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | N | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.