Basic Information
| Provider Information | |||||||||
| NPI: | 1942637053 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BERESKY | ||||||||
| FirstName: | ARAM | ||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
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| OtherLastName: | BERESKY | ||||||||
| OtherFirstName: | JOHN | ||||||||
| OtherMiddleName: | |||||||||
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| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1027 E. BURNSIDE ST. | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97214 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032398400 | ||||||||
| FaxNumber: | 5032398407 | ||||||||
| Practice Location | |||||||||
| Address1: | 10362 SW MCDONALD ST | ||||||||
| Address2: | |||||||||
| City: | TIGARD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972244863 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5036240312 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2013 | ||||||||
| LastUpdateDate: | 02/11/2015 | ||||||||
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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 | 101YA0400X | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YM0800X | N | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.