Provider Demographics
NPI:1275782591
Name:KILEY, SUSAN J (LICSW, LMP, LMT)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:J
Last Name:KILEY
Suffix:
Gender:F
Credentials:LICSW, LMP, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2734 NE BRYCE ST.
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97212
Mailing Address - Country:US
Mailing Address - Phone:503-807-6880
Mailing Address - Fax:
Practice Address - Street 1:2734 NE BRYCE ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97212-1638
Practice Address - Country:US
Practice Address - Phone:503-807-6880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-10
Last Update Date:2008-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW000062471041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical