Basic Information
| Provider Information | |||||||||
| NPI: | 1134575806 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PERRY | ||||||||
| FirstName: | RAYMOND | ||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | PERRY | ||||||||
| OtherFirstName: | CHRIS | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | QMHA | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1790 W 11TH AVE | ||||||||
| Address2: | STE 200 | ||||||||
| City: | EUGENE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974023758 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412462259 | ||||||||
| FaxNumber: | 5413457605 | ||||||||
| Practice Location | |||||||||
| Address1: | 1790 W 11TH AVE | ||||||||
| Address2: | STE 200 | ||||||||
| City: | EUGENE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974023758 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412462259 | ||||||||
| FaxNumber: | 5413457605 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2016 | ||||||||
| LastUpdateDate: | 05/11/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.