Provider Demographics
NPI:1245240001
Name:KOSSOVER-WECHTER, DENISE (AUD)
Entity type:Individual
Prefix:
First Name:DENISE
Middle Name:
Last Name:KOSSOVER-WECHTER
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:DENISE
Other - Middle Name:
Other - Last Name:KOSSOVER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:AUD
Mailing Address - Street 1:1040 NW 22ND AVE
Mailing Address - Street 2:SUITE 460
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97210-3057
Mailing Address - Country:US
Mailing Address - Phone:503-413-8154
Mailing Address - Fax:503-413-6944
Practice Address - Street 1:1040 NW 22ND AVE
Practice Address - Street 2:SUITE 460
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210-3057
Practice Address - Country:US
Practice Address - Phone:503-413-8154
Practice Address - Fax:503-413-6944
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR20846231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR003330Medicaid
ORR98939Medicare UPIN
OR104864Medicare ID - Type Unspecified