Provider Demographics
NPI:1790109064
Name:KOVACH, KATHRYN SPORING (LPC, LAT, ATC)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:SPORING
Last Name:KOVACH
Suffix:
Gender:F
Credentials:LPC, LAT, ATC
Other - Prefix:
Other - First Name:KATHRYN
Other - Middle Name:
Other - Last Name:SPORING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1020 SW TAYLOR ST STE 640
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97205-2511
Mailing Address - Country:US
Mailing Address - Phone:503-308-1538
Mailing Address - Fax:
Practice Address - Street 1:1020 SW TAYLOR ST STE 640
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97205-2511
Practice Address - Country:US
Practice Address - Phone:503-308-1538
Practice Address - Fax:503-739-8956
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-07
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORR6392101YM0800X
MDA005822255A2300X
ORC7415101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR50078660Medicaid