Provider Demographics
NPI:1114218880
Name:KLOCKNER, PRISCILLA (MA)
Entity Type:Individual
Prefix:
First Name:PRISCILLA
Middle Name:
Last Name:KLOCKNER
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:712 SE HAWTHORNE BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-3538
Mailing Address - Country:US
Mailing Address - Phone:503-954-2188
Mailing Address - Fax:503-327-8005
Practice Address - Street 1:712 SE HAWTHORNE BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214-3538
Practice Address - Country:US
Practice Address - Phone:503-954-2188
Practice Address - Fax:503-327-8005
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-28
Last Update Date:2011-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional