Provider Demographics
NPI:1285970327
Name:PONTI-FOSS, KOREL (MA, LMFT, ATR)
Entity type:Individual
Prefix:
First Name:KOREL
Middle Name:
Last Name:PONTI-FOSS
Suffix:
Gender:M
Credentials:MA, LMFT, ATR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7831 SE STARK ST
Mailing Address - Street 2:SUITE 202
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97215-2357
Mailing Address - Country:US
Mailing Address - Phone:503-956-6133
Mailing Address - Fax:
Practice Address - Street 1:5932 NE GLISAN ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-3754
Practice Address - Country:US
Practice Address - Phone:503-956-6133
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-18
Last Update Date:2016-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORT1102106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist