Provider Demographics
NPI:1356439970
Name:SUMNER, IVAN KENT (LCSW)
Entity Type:Individual
Prefix:
First Name:IVAN
Middle Name:KENT
Last Name:SUMNER
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1524 WILLAMETTE ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97401-4093
Mailing Address - Country:US
Mailing Address - Phone:541-515-2009
Mailing Address - Fax:541-342-5545
Practice Address - Street 1:1524 WILLAMETTE ST
Practice Address - Street 2:SUITE 101
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-4093
Practice Address - Country:US
Practice Address - Phone:541-515-2009
Practice Address - Fax:541-342-5545
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2010-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1487101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR0000TLDBNMedicare ID - Type Unspecified