Provider Demographics
NPI:1932117066
Name:KAUTZER, MARY F (LCSW)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:F
Last Name:KAUTZER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 8459
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97207-8459
Mailing Address - Country:US
Mailing Address - Phone:503-489-2225
Mailing Address - Fax:
Practice Address - Street 1:400 NE 7TH ST
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-5604
Practice Address - Country:US
Practice Address - Phone:503-489-2225
Practice Address - Fax:503-661-4959
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2008-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
L10161041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
R79809Medicare UPIN
117854Medicare ID - Type Unspecified