Provider Demographics
NPI:1275806887
Name:TEBOW, KRISTIN L (MS)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:L
Last Name:TEBOW
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2303 NE 12TH AVE APT 3
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97212-4138
Mailing Address - Country:US
Mailing Address - Phone:503-850-8463
Mailing Address - Fax:
Practice Address - Street 1:2303 NE 12TH AVE APT 3
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97212-4138
Practice Address - Country:US
Practice Address - Phone:503-850-8463
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-13
Last Update Date:2021-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC3524101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health