Provider Demographics
NPI:1235872920
Name:VAN DE COEVERING, KATHERINE M (RN/QMHP)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:M
Last Name:VAN DE COEVERING
Suffix:
Gender:F
Credentials:RN/QMHP
Other - Prefix:
Other - First Name:KATIE
Other - Middle Name:M
Other - Last Name:VAN DE COEVERING
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RN/QMHP
Mailing Address - Street 1:1776 SW MADISON ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97205-1715
Mailing Address - Country:US
Mailing Address - Phone:503-224-1044
Mailing Address - Fax:503-621-2235
Practice Address - Street 1:12360 E BURNSIDE ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97233-1042
Practice Address - Country:US
Practice Address - Phone:971-279-4800
Practice Address - Fax:971-279-2051
Is Sole Proprietor?:No
Enumeration Date:2022-04-19
Last Update Date:2023-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR101YM0800X
WARN61311920163W00000X
OR201608013RN163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500805925Medicaid