Basic Information
| Provider Information | |||||||||
| NPI: | 1699944462 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PERISICH | ||||||||
| FirstName: | KERRI | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12636 SE STARK ST | ||||||||
| Address2: | PLAZA 125, BUILDING J | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972331058 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032534600 | ||||||||
| FaxNumber: | 5032534609 | ||||||||
| Practice Location | |||||||||
| Address1: | 12636 SE STARK ST | ||||||||
| Address2: | PLAZA 125, BUILDING J | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972331058 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032534600 | ||||||||
| FaxNumber: | 5032534609 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/26/2008 | ||||||||
| LastUpdateDate: | 06/10/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 101Y00000X | Y | Behavioral Health & Social Service Providers | Counselor |
ID Information
| ID | Type | State | Issuer | Description | 230442 | 01 | OR | DMAP | OTHER |