Provider Demographics
NPI:1184902504
Name:MIYASATO, KEVIN C (LCSW)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:C
Last Name:MIYASATO
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12725 SW MILLIKAN WAY
Mailing Address - Street 2:SUITE 300
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97005-1678
Mailing Address - Country:US
Mailing Address - Phone:503-906-7870
Mailing Address - Fax:503-906-7871
Practice Address - Street 1:12725 SW MILLIKAN WAY
Practice Address - Street 2:SUITE 300
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97005-1678
Practice Address - Country:US
Practice Address - Phone:503-906-7870
Practice Address - Fax:503-906-7871
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-02
Last Update Date:2014-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV00686101YA0400X
NV5214-S1041C0700X
OR58551041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500670052Medicaid