Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225XM0800X | Mental Health |
NPI | 1689227704 |
---|---|
Provider Name | Kylie Shay Mcdermott |
First Address | Portland, OR 97229-5442 |
Second Address | Milwaukie, OR 97222-8855 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 17/07/2019 |
Last Update Date | 17/07/2019 |