Provider Demographics
NPI:1225348394
Name:KETCHUM, KRISTI (MSW, LCSW)
Entity Type:Individual
Prefix:
First Name:KRISTI
Middle Name:
Last Name:KETCHUM
Suffix:
Gender:F
Credentials:MSW, 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 1034
Mailing Address - Street 2:P3-WC1
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97207-1034
Mailing Address - Country:US
Mailing Address - Phone:503-220-8262
Mailing Address - Fax:503-402-2939
Practice Address - Street 1:3710 SW US VETERANS HOSPITAL RD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-2964
Practice Address - Country:US
Practice Address - Phone:503-220-8262
Practice Address - Fax:503-402-2939
Is Sole Proprietor?:No
Enumeration Date:2010-10-07
Last Update Date:2012-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL52641041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical