Provider Demographics
NPI:1669962536
Name:KANSO, TEREK (PSYD, LPC)
Entity type:Individual
Prefix:DR
First Name:TEREK
Middle Name:
Last Name:KANSO
Suffix:
Gender:M
Credentials:PSYD, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10127 SW 59TH PL
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97219-5708
Mailing Address - Country:US
Mailing Address - Phone:503-866-9688
Mailing Address - Fax:
Practice Address - Street 1:10127 SW 59TH PL
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97219-5708
Practice Address - Country:US
Practice Address - Phone:503-866-9688
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-15
Last Update Date:2018-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC4721101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional