Basic Information
| Provider Information | |||||||||
| NPI: | 1376176644 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MITSINA-BROWN | ||||||||
| FirstName: | SVIATLANA | ||||||||
| MiddleName: | |||||||||
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| Credential: | PSYD | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | MITSINA | ||||||||
| OtherFirstName: | SVETLANA | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | PSYD | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 15480 SW BUNTING ST APT 106 | ||||||||
| Address2: | |||||||||
| City: | BEAVERTON | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970078784 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032779505 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2600 CENTER ST NE | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973012669 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5039452800 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/14/2020 | ||||||||
| LastUpdateDate: | 02/14/2020 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 2694 | OR | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.