Provider Demographics
NPI:1538360003
Name:KORNELIS, KEN (PHD)
Entity type:Individual
Prefix:DR
First Name:KEN
Middle Name:
Last Name:KORNELIS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15110 BOONES FERRY RD
Mailing Address - Street 2:STE 100E
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97035-3452
Mailing Address - Country:US
Mailing Address - Phone:503-636-8654
Mailing Address - Fax:503-636-5630
Practice Address - Street 1:15110 BOONES FERRY RD
Practice Address - Street 2:STE 100E
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97035-3452
Practice Address - Country:US
Practice Address - Phone:503-538-6045
Practice Address - Fax:503-538-1598
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-30
Last Update Date:2017-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR872103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR101101Medicare ID - Type Unspecified