Basic Information
| Provider Information | |||||||||
| NPI: | 1730470071 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MACKINTOSH | ||||||||
| FirstName: | COLLEEN | ||||||||
| MiddleName: | |||||||||
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| NameSuffix: | |||||||||
| Credential: | ATR LPC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DUNCAN | ||||||||
| OtherFirstName: | COLLEEN | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | ATR LPC | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 8490 SW NESTUCCA CT | ||||||||
| Address2: | |||||||||
| City: | TUALATIN | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970629108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9712072538 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1904 SE DIVISION ST | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972021146 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5035178663 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/20/2011 | ||||||||
| LastUpdateDate: | 02/27/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
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| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | OR | N | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 101YP2500X | C3423 | OR | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.