Basic Information
| Provider Information | |||||||||
| NPI: | 1396377990 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KANALLAKAN | ||||||||
| FirstName: | AMBER | ||||||||
| MiddleName: | L | ||||||||
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| Mailing Information | |||||||||
| Address1: | 113 N ELM ST | ||||||||
| Address2: | |||||||||
| City: | CANBY | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970133519 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032638903 | ||||||||
| FaxNumber: | 5032668632 | ||||||||
| Practice Location | |||||||||
| Address1: | 5291 NE ELAM YOUNG PKWY STE 160 | ||||||||
| Address2: | |||||||||
| City: | HILLSBORO | ||||||||
| State: | OR | ||||||||
| PostalCode: | 971247560 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5033725147 | ||||||||
| FaxNumber: | 5036504302 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/11/2020 | ||||||||
| LastUpdateDate: | 11/17/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 106H00000X | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.