Basic Information
| Provider Information | |||||||||
| NPI: | 1134267875 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BENTLEY | ||||||||
| FirstName: | KATHERINE | ||||||||
| MiddleName: | ELOISE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MSW, LCSW, CADC I | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4208 SE STARK ST | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972151644 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5033349668 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3550 N INTERSTATE AVE | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972271196 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032493434 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/02/2007 | ||||||||
| LastUpdateDate: | 12/23/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 12/21/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 04-07-01 | OR | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.