Provider Demographics
NPI:1467496901
Name:MOLKO, DAVID M (LCSW)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:M
Last Name:MOLKO
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 1:1221 SW YAMHILL ST
Mailing Address - Street 2:STE 301
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97205-2110
Mailing Address - Country:US
Mailing Address - Phone:503-226-7079
Mailing Address - Fax:503-226-1130
Practice Address - Street 1:1221 SW YAMHILL ST
Practice Address - Street 2:#301
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97205-2126
Practice Address - Country:US
Practice Address - Phone:503-226-7079
Practice Address - Fax:503-226-1130
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2017-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL29691041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR108448Medicare ID - Type UnspecifiedMEDICARE PROVIDER ID