Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 101YM0800X | Mental Health Counselor | C3288 | OR |
NPI | 1003234188 |
---|---|
Provider Name | Michael Kubetz |
First Address | Portland, OR 97211-4042 |
Second Address | Portland, OR 97211-4042 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 04/04/2014 |
Last Update Date | 04/04/2014 |