Provider Demographics
NPI:1508830530
Name:OUTLAND, MARY KATHRYN (MSW, LCSW)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:KATHRYN
Last Name:OUTLAND
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:KATHY
Other - Middle Name:
Other - Last Name:OUTLAND
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MSW, LCSW
Mailing Address - Street 1:4035 12TH STREET CUTOFF SE
Mailing Address - Street 2:SUITE 140
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302
Mailing Address - Country:US
Mailing Address - Phone:503-363-8075
Mailing Address - Fax:503-315-7571
Practice Address - Street 1:4035 12TH STREET CUTOFF SE
Practice Address - Street 2:SUITE 140
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302
Practice Address - Country:US
Practice Address - Phone:503-363-8075
Practice Address - Fax:503-315-7571
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2015-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR11781041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OROOOTLCRAMedicare UPIN