Provider Demographics
NPI:1427351287
Name:BACK, KATHY L (MA, LPC)
Entity type:Individual
Prefix:MRS
First Name:KATHY
Middle Name:L
Last Name:BACK
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2735 ENCHANTED VIEW LN SE
Mailing Address - Street 2:
Mailing Address - City:TURNER
Mailing Address - State:OR
Mailing Address - Zip Code:97392-9586
Mailing Address - Country:US
Mailing Address - Phone:503-991-2176
Mailing Address - Fax:
Practice Address - Street 1:2645 PORTLAND RD NE
Practice Address - Street 2:SUITE 120
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-0198
Practice Address - Country:US
Practice Address - Phone:503-798-3180
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-15
Last Update Date:2012-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC2766101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health