Provider Demographics
NPI:1013179316
Name:PANK, JOHN (LCSW)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:PANK
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3395
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3395
Mailing Address - Country:US
Mailing Address - Phone:503-215-4300
Mailing Address - Fax:503-215-0340
Practice Address - Street 1:205 NE 50TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-2909
Practice Address - Country:US
Practice Address - Phone:503-215-2678
Practice Address - Fax:503-215-2688
Is Sole Proprietor?:No
Enumeration Date:2008-06-27
Last Update Date:2008-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR7751041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical