Provider Demographics
NPI:1750431649
Name:SHOTWELL KUBO, LANA JOY (MA)
Entity type:Individual
Prefix:
First Name:LANA
Middle Name:JOY
Last Name:SHOTWELL KUBO
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:LANA
Other - Middle Name:JOY
Other - Last Name:SHOTWELL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MA
Mailing Address - Street 1:3415 SE POWELL BLVD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97202-3371
Mailing Address - Country:US
Mailing Address - Phone:503-813-7705
Mailing Address - Fax:503-205-0188
Practice Address - Street 1:3415 SE POWELL BLVD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97202-3371
Practice Address - Country:US
Practice Address - Phone:503-813-7705
Practice Address - Fax:503-205-0188
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2010-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
ORC2396101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health