Provider Demographics
NPI:1124033618
Name:KRUMMENACKER, MICHELLE L (LCSW)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:L
Last Name:KRUMMENACKER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10117 SE SUNNYSIDE RD
Mailing Address - Street 2:SUITE F, BOX 1217
Mailing Address - City:CLACKAMAS
Mailing Address - State:OR
Mailing Address - Zip Code:97015-7708
Mailing Address - Country:US
Mailing Address - Phone:503-740-1971
Mailing Address - Fax:503-771-2436
Practice Address - Street 1:9123 SE SAINT HELENS ST STE 100F
Practice Address - Street 2:
Practice Address - City:CLACKAMAS
Practice Address - State:OR
Practice Address - Zip Code:97015-6800
Practice Address - Country:US
Practice Address - Phone:503-740-1971
Practice Address - Fax:503-771-2436
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2021-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR98-07-34101YA0400X
ORL31971041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR116499Medicare ID - Type Unspecified
ORP94143Medicare UPIN