Provider Demographics
NPI:1306198320
Name:MONGER, KIRSTEN MELISSA (LPC)
Entity Type:Individual
Prefix:
First Name:KIRSTEN
Middle Name:MELISSA
Last Name:MONGER
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:604 NE 93RD AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97220-4538
Mailing Address - Country:US
Mailing Address - Phone:971-335-9310
Mailing Address - Fax:971-202-1574
Practice Address - Street 1:2355 STATE ST STE 101
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-4541
Practice Address - Country:US
Practice Address - Phone:971-335-9310
Practice Address - Fax:971-202-1574
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-15
Last Update Date:2023-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC4532101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500701921Medicaid