Provider Demographics
NPI:1225475387
Name:MENASCO, KEVIN DAVID MICHAEL (LCSW)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:DAVID MICHAEL
Last Name:MENASCO
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 1:32 NE 11TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97232
Mailing Address - Country:US
Mailing Address - Phone:978-979-6094
Mailing Address - Fax:
Practice Address - Street 1:32 NE 11TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232
Practice Address - Country:US
Practice Address - Phone:978-979-6094
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-30
Last Update Date:2022-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
ORL95181041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101Y00000XBehavioral Health & Social Service ProvidersCounselor