Basic Information
| Provider Information | |||||||||
| NPI: | 1730261017 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KRAKE-BETCHER | ||||||||
| FirstName: | TONYA | ||||||||
| MiddleName: | D. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | L.P.C. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WALKER-COOK | ||||||||
| OtherFirstName: | TONYA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 12636 SE STARK ST | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972331058 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032534600 | ||||||||
| FaxNumber: | 5032534609 | ||||||||
| Practice Location | |||||||||
| Address1: | 12636 SE STARK ST | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972331058 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5038534600 | ||||||||
| FaxNumber: | 5038594609 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/19/2006 | ||||||||
| LastUpdateDate: | 09/23/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YA0400X | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YP2500X | C3042 | OR | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 164936 | 05 | OR | MEDICAID |