Provider Demographics
NPI:1346326527
Name:NISSILA, KATHLEEN G (LICENSED PROFESSIONA)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:G
Last Name:NISSILA
Suffix:
Gender:F
Credentials:LICENSED PROFESSIONA
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:ANN
Other - Last Name:GULLICKSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2622 NE 30TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97212-4926
Mailing Address - Country:US
Mailing Address - Phone:503-281-0262
Mailing Address - Fax:
Practice Address - Street 1:2622 NE 30TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97212-4926
Practice Address - Country:US
Practice Address - Phone:503-281-0262
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC1030101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional