Provider Demographics
NPI:1962004358
Name:KENNEMER & SMITH PSYCHOLOGICAL SERVICES LLC
Entity Type:Organization
Organization Name:KENNEMER & SMITH PSYCHOLOGICAL SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:ALENE
Authorized Official - Middle Name:
Authorized Official - Last Name:CERASUOLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-303-4257
Mailing Address - Street 1:619 MADISON ST STE 108
Mailing Address - Street 2:
Mailing Address - City:OREGON CITY
Mailing Address - State:OR
Mailing Address - Zip Code:97045-2354
Mailing Address - Country:US
Mailing Address - Phone:503-303-4257
Mailing Address - Fax:503-387-3957
Practice Address - Street 1:619 MADISON ST STE 108
Practice Address - Street 2:
Practice Address - City:OREGON CITY
Practice Address - State:OR
Practice Address - Zip Code:97045-2354
Practice Address - Country:US
Practice Address - Phone:503-303-4257
Practice Address - Fax:503-387-3957
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-11
Last Update Date:2020-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500602612Medicaid