Basic Information
| Provider Information | |||||||||
| NPI: | 1164404836 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KOHLER | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | JOHN | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2415 SE 43RD AVE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972061600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032380705 | ||||||||
| FaxNumber: | 5032367166 | ||||||||
| Practice Location | |||||||||
| Address1: | 2415 SE 43RD AVE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972061600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032380705 | ||||||||
| FaxNumber: | 5032367166 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/17/2005 | ||||||||
| LastUpdateDate: | 09/06/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 1706 | OR | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical | 101YA0400X | 02-03-28 | OR | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 089784006 | 01 | OR | BC/BS | OTHER |