Provider Demographics
NPI:1376952796
Name:AYALA, JOAN KENDALL (LCSW CADC III CRM)
Entity Type:Individual
Prefix:MS
First Name:JOAN
Middle Name:KENDALL
Last Name:AYALA
Suffix:
Gender:F
Credentials:LCSW CADC III CRM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12265 SW DENFIELD ST
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97005-1704
Mailing Address - Country:US
Mailing Address - Phone:971-226-1501
Mailing Address - Fax:971-339-0401
Practice Address - Street 1:610 SW ALDER ST STE 915
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97205
Practice Address - Country:US
Practice Address - Phone:971-226-1501
Practice Address - Fax:503-335-8125
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-11
Last Update Date:2021-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR17-01-28101Y00000X
101YA0400X, 101YM0800X, 104100000X
ORL7815101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR16CRM233OtherACCBO CRM
ORL7825OtherLICENSED CLINICAL SOCIAL WORKER
ORA4288OtherBOARD OF LICENSED CLINICAL SOCIAL WORKERS
OR17-01-0128OtherACCBO CADC III