Provider Demographics
NPI:1629820071
Name:KOSIK, KEVIN R (CADC-R ,QMHA-R)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:R
Last Name:KOSIK
Suffix:
Gender:M
Credentials:CADC-R ,QMHA-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7612 SE CARLTON ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97206-6438
Mailing Address - Country:US
Mailing Address - Phone:503-310-4162
Mailing Address - Fax:
Practice Address - Street 1:8041 E BURNSIDE ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97215-1548
Practice Address - Country:US
Practice Address - Phone:503-252-3304
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-01
Last Update Date:2024-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORT-24-3714101YA0400X
ORQMHA-R-5143101YM0800X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)