Provider Demographics
NPI:1780562512
Name:KOSMAS, PANTELIS
Entity type:Individual
Prefix:
First Name:PANTELIS
Middle Name:
Last Name:KOSMAS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:PONNY
Other - Middle Name:
Other - Last Name:KOSMAS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:5601 SE 50TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97206-5679
Mailing Address - Country:US
Mailing Address - Phone:503-916-6380
Mailing Address - Fax:
Practice Address - Street 1:5601 SE 50TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97206-5679
Practice Address - Country:US
Practice Address - Phone:503-916-6380
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-08-21
Last Update Date:2025-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR156499101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool