Provider Demographics
NPI:1174169890
Name:PACNORTHWEST COUNSELING
Entity type:Organization
Organization Name:PACNORTHWEST COUNSELING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED CLINICAL SOCIAL WORKER
Authorized Official - Prefix:
Authorized Official - First Name:COLLIN
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIDSON
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:503-730-5760
Mailing Address - Street 1:PO BOX 1677
Mailing Address - Street 2:
Mailing Address - City:FAIRVIEW
Mailing Address - State:OR
Mailing Address - Zip Code:97024-1677
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6018 SE STARK ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97215-1990
Practice Address - Country:US
Practice Address - Phone:503-730-5760
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-11-19
Last Update Date:2019-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)