Provider Demographics
NPI:1740586601
Name:MYERS SUGAHARA, KELLY ERIN (LCSW)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:ERIN
Last Name:MYERS SUGAHARA
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:ERIN
Other - Last Name:MYERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 3158
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3158
Mailing Address - Country:US
Mailing Address - Phone:503-215-6494
Mailing Address - Fax:
Practice Address - Street 1:9155 SW BARNES RD STE 333
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-6630
Practice Address - Country:US
Practice Address - Phone:503-216-5102
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-02-09
Last Update Date:2023-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL67921041C0700X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical