Provider Demographics
NPI:1306368477
Name:HEADRICK, KRISTINA CAROLYN (MSW)
Entity Type:Individual
Prefix:
First Name:KRISTINA
Middle Name:CAROLYN
Last Name:HEADRICK
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:KRISTINA
Other - Middle Name:CAROLYN
Other - Last Name:LAFFERTY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:707 SW GAINES ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-2901
Mailing Address - Country:US
Mailing Address - Phone:503-494-2781
Mailing Address - Fax:503-418-5215
Practice Address - Street 1:707 SW GAINES ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-2901
Practice Address - Country:US
Practice Address - Phone:503-494-2762
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-11
Last Update Date:2021-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORA47311041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical