Provider Demographics
NPI:1255178844
Name:CASANOVA, CARL I (MS,)
Entity type:Individual
Prefix:
First Name:CARL
Middle Name:
Last Name:CASANOVA
Suffix:I
Gender:M
Credentials:MS,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11650 SW 67TH AVE STE 230
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97223-8590
Mailing Address - Country:US
Mailing Address - Phone:503-422-1143
Mailing Address - Fax:
Practice Address - Street 1:11650 SW 67TH AVE STE 230
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97223-8590
Practice Address - Country:US
Practice Address - Phone:503-422-1143
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-10
Last Update Date:2024-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional