Basic Information
| Provider Information | |||||||||
| NPI: | 1942693502 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLOUD | ||||||||
| FirstName: | KASIE | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MSW, CSWA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | FREDERICKSON | ||||||||
| OtherFirstName: | KASIE | ||||||||
| OtherMiddleName: | M | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1027 E. BURNSIDE ST. | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97214 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032398400 | ||||||||
| FaxNumber: | 5032698407 | ||||||||
| Practice Location | |||||||||
| Address1: | 1030 NE COUCH ST. | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97232 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032398400 | ||||||||
| FaxNumber: | 5032398407 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/06/2015 | ||||||||
| LastUpdateDate: | 03/06/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.