Provider Demographics
NPI:1780730705
Name:VAN DOREN, KATHERIN THOMSON (MA COUNSELING ART TX)
Entity type:Individual
Prefix:MS
First Name:KATHERIN
Middle Name:THOMSON
Last Name:VAN DOREN
Suffix:
Gender:F
Credentials:MA COUNSELING ART TX
Other - Prefix:
Other - First Name:KATE
Other - Middle Name:T
Other - Last Name:PHIPPS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MAAT
Mailing Address - Street 1:1315 SE 35TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-4235
Mailing Address - Country:US
Mailing Address - Phone:916-212-2258
Mailing Address - Fax:
Practice Address - Street 1:4790 N LOMBARD ST
Practice Address - Street 2:MORRISON CENTER
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97203-4565
Practice Address - Country:US
Practice Address - Phone:503-258-4557
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-25
Last Update Date:2009-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
OR101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
7722Medicare UPIN