Provider Demographics
NPI:1356428395
Name:ANDERT, KENNETH L (LCSW)
Entity type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:L
Last Name:ANDERT
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 1:1020 SW TAYLOR ST STE 370
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97205-2573
Mailing Address - Country:US
Mailing Address - Phone:503-421-5904
Mailing Address - Fax:
Practice Address - Street 1:1020 SW TAYLOR ST STE 370
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97205-2573
Practice Address - Country:US
Practice Address - Phone:503-421-5904
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR14231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR115476Medicare ID - Type Unspecified