NPIMap

Organization Active NPI

Tiffany Kettermann, LLC

  • Mental Health Counselor
  • Portland, OR
National Provider Identifier
1003461740
Registry record updated Feb 25, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Mental Health CounselorTaxonomy code 101YM0800X
Legal business name
TIFFANY KETTERMANN, LLC
Practice address
2950 SE Stark St Ste 130
Portland, OR 97214-3082
Phone
(971) 270-0167
NPI assigned
Aug 8, 2019
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Feb 25, 2025

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Tiffany Kettermann, LPC, LMHC, CADCINPI 1194067355
Title
Ceo
Phone
(971) 270-0167

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Addiction (Substance Use Disorder) CounselorGroup: 193200000X MULTI-SPECIALTY GROUP 101YA0400X
Mental Health CounselorGroup: 193200000X MULTI-SPECIALTY GROUP 101YM0800X Primary

Addresses

Primary practice location

2950 SE Stark St Ste 130
Portland, OR 97214-3082

Mailing address

2950 SE Stark St Ste 130
Portland, OR 97214-3082
Phone (971) 270-0167

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in OR

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20220923001810 OR Part B Supplier - Clinic/Group Practice 0941685184 Receives reassigned benefits from 14 practitioners
Practice locations: Portland, OR

National Provider Directory

National Provider Directory

Locations

2950 SE Stark St
Ste 130
Portland, OR 97214
Phone (971) 270-0167

Practitioners & affiliated clinicians

Practitioners 35

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

View all 35

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1565222400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1740441600000",
    "number": "1003461740",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2950 SE STARK ST STE 130",
            "city": "PORTLAND",
            "state": "OR",
            "postal_code": "972143082",
            "telephone_number": "971-270-0167"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2950 SE STARK ST STE 130",
            "city": "PORTLAND",
            "state": "OR",
            "postal_code": "972143082",
            "telephone_number": "971-270-0167"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "TIFFANY KETTERMANN, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2019-08-08",
        "last_updated": "2025-02-25",
        "certification_date": "2025-02-25",
        "status": "A",
        "authorized_official_last_name": "KETTERMANN",
        "authorized_official_first_name": "TIFFANY",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "971-270-0167",
        "authorized_official_credential": "LPC, LMHC, CADCI"
    },
    "taxonomies": [
        {
            "code": "101YA0400X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Counselor, Addiction (Substance Use Disorder)",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "101YM0800X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Counselor, Mental Health",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Portland, OR

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 25, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.