Basic Information
| Provider Information | |||||||||
| NPI: | 1235533308 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KLEINHENZ | ||||||||
| FirstName: | JOSEPH | ||||||||
| MiddleName: | C | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW, CADC 1 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4622 NE 21ST AVE | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972115829 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032874796 | ||||||||
| FaxNumber: | 5033358636 | ||||||||
| Practice Location | |||||||||
| Address1: | 2318 NE MLK JR BLVD | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972123715 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5038020302 | ||||||||
| FaxNumber: | 5033358636 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2014 | ||||||||
| LastUpdateDate: | 07/08/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/08/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 04-07-26 | OR | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 1041C0700X | L8062 | OR | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 500662131 | 05 | OR | MEDICAID |