Basic Information
| Provider Information | |||||||||
| NPI: | 1295343473 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COLVIN | ||||||||
| FirstName: | KAYLA | ||||||||
| MiddleName: | |||||||||
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| Credential: | PSS, CRM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10621 SE LINWOOD AVE | ||||||||
| Address2: | |||||||||
| City: | MILWAUKIE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972222710 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412171609 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2720 NE FLANDERS ST | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972323160 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032385203 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2020 | ||||||||
| LastUpdateDate: | 07/14/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
ID Information
| ID | Type | State | Issuer | Description | THW000004102 | 01 | OR | TRADITIONAL HEALTH WORKER, STATE OF OREGON | OTHER | 10-CRM-290 | 01 | OR | MHACBO | OTHER |