Provider Demographics
NPI:1689919656
Name:DAUGHERTY CALHOUN, CORINA ANNE
Entity Type:Individual
Prefix:
First Name:CORINA
Middle Name:ANNE
Last Name:DAUGHERTY CALHOUN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13210 SE DIVISION ST
Mailing Address - Street 2:APT 13
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97236-3058
Mailing Address - Country:US
Mailing Address - Phone:509-294-5001
Mailing Address - Fax:
Practice Address - Street 1:847 NE 19TH AVE STE 100
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232
Practice Address - Country:US
Practice Address - Phone:503-238-0769
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-03
Last Update Date:2018-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health