1194109496 NPI number — CHRISTIAN CAROL PERALTA MSW, CSWA, QMHP

Table of content: CHRISTIAN CAROL PERALTA MSW, CSWA, QMHP (NPI 1194109496)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194109496 NPI number — CHRISTIAN CAROL PERALTA MSW, CSWA, QMHP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PERALTA
Provider First Name:
CHRISTIAN
Provider Middle Name:
CAROL
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MSW, CSWA, QMHP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1194109496
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/29/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11035 NE SANDY BOULEVARD, PORTLAND
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORTLAND
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97220
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-258-4200
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
965 TUCKER RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HOOD RIVER
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97031-9591
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-386-6665
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/16/2015

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 171M00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)





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