Provider Demographics
NPI:1194067355
Name:KETTERMANN, TIFFANY (LPC, CADCI)
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:KETTERMANN
Suffix:
Gender:F
Credentials:LPC, CADCI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7415 N OATMAN AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97217-1213
Mailing Address - Country:US
Mailing Address - Phone:971-270-0167
Mailing Address - Fax:
Practice Address - Street 1:7415 N OATMAN AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97217-1213
Practice Address - Country:US
Practice Address - Phone:971-270-0167
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-25
Last Update Date:2015-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)