Basic Information
| Provider Information | |||||||||
| NPI: | 1013055995 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ALEXANDER | ||||||||
| FirstName: | MARI | ||||||||
| MiddleName: | KRESGE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C, LMFT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | RILEY-KRESGE | ||||||||
| OtherFirstName: | MARI | ||||||||
| OtherMiddleName: | ELIZABETH | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PA-C, LMFT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 568 | ||||||||
| Address2: | |||||||||
| City: | CORNELIUS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 971130568 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5033528657 | ||||||||
| FaxNumber: | 5033528658 | ||||||||
| Practice Location | |||||||||
| Address1: | 226 SE 8TH AVE | ||||||||
| Address2: | |||||||||
| City: | HILLSBORO | ||||||||
| State: | OR | ||||||||
| PostalCode: | 971234218 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5036017400 | ||||||||
| FaxNumber: | 5036017311 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/02/2007 | ||||||||
| LastUpdateDate: | 05/19/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | T0523 | OR | N | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 363A00000X | PA01219 | OR | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 500669279 | 05 | OR | MEDICAID |