Provider Demographics
NPI:1275102303
Name:KEITH, KIRSEN (CSWA)
Entity Type:Individual
Prefix:
First Name:KIRSEN
Middle Name:
Last Name:KEITH
Suffix:
Gender:M
Credentials:CSWA
Other - Prefix:
Other - First Name:KASPAR
Other - Middle Name:CAMERON
Other - Last Name:WOODS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:3917 SE 99TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97266-2508
Mailing Address - Country:US
Mailing Address - Phone:503-764-8026
Mailing Address - Fax:
Practice Address - Street 1:3620 SE POWELL BLVD # 102
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97202-1880
Practice Address - Country:US
Practice Address - Phone:503-486-8936
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-23
Last Update Date:2021-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORA123231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical