Provider Demographics
NPI:1154652733
Name:SPERRY, DONNA
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:
Last Name:SPERRY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2328 CRESTVIEW DR S
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302-5363
Mailing Address - Country:US
Mailing Address - Phone:586-255-6228
Mailing Address - Fax:
Practice Address - Street 1:694 CHURCH ST NE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-2401
Practice Address - Country:US
Practice Address - Phone:503-588-5827
Practice Address - Fax:503-315-0714
Is Sole Proprietor?:No
Enumeration Date:2010-01-21
Last Update Date:2010-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301008670103TC0700X
OR2073103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical