Provider Demographics
NPI:1720664592
Name:CONVERSE, KATHLEEN GRACE
Entity Type:Individual
Prefix:MRS
First Name:KATHLEEN
Middle Name:GRACE
Last Name:CONVERSE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5234 N OBERLIN ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97203-4327
Mailing Address - Country:US
Mailing Address - Phone:509-432-5364
Mailing Address - Fax:
Practice Address - Street 1:975 SE SANDY BLVD STE 100
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214-1399
Practice Address - Country:US
Practice Address - Phone:503-427-1952
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-22
Last Update Date:2021-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker