Provider Demographics
NPI:1710540869
Name:LIX, KASEY M (LPC INTERN R5121)
Entity Type:Individual
Prefix:
First Name:KASEY
Middle Name:M
Last Name:LIX
Suffix:
Gender:F
Credentials:LPC INTERN R5121
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10305 SE BELL AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKIE
Mailing Address - State:OR
Mailing Address - Zip Code:97222-2230
Mailing Address - Country:US
Mailing Address - Phone:503-267-1761
Mailing Address - Fax:
Practice Address - Street 1:948 NE 102ND AVE STE 101
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97220-4064
Practice Address - Country:US
Practice Address - Phone:503-257-0381
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-15
Last Update Date:2019-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORR5121101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health