Basic Information
| Provider Information | |||||||||
| NPI: | 1992258958 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PEREZ-MEDINA | ||||||||
| FirstName: | ALEXIS | ||||||||
| MiddleName: | LLEMAL | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PEREZ | ||||||||
| OtherFirstName: | ALEX | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | MR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 906 MAIN AVE | ||||||||
| Address2: | |||||||||
| City: | TILLAMOOK | ||||||||
| State: | OR | ||||||||
| PostalCode: | 971413816 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5038428201 | ||||||||
| FaxNumber: | 5038151870 | ||||||||
| Practice Location | |||||||||
| Address1: | 906 MAIN AVE | ||||||||
| Address2: | |||||||||
| City: | TILLAMOOK | ||||||||
| State: | OR | ||||||||
| PostalCode: | 971413816 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5038428201 | ||||||||
| FaxNumber: | 5038151870 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/26/2016 | ||||||||
| LastUpdateDate: | 07/18/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YM0800X | OR | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 500714618 | 05 | OR | MEDICAID |