Provider Demographics
NPI:1265831705
Name:BACKSTRAND, SERITA (PSYD)
Entity Type:Individual
Prefix:DR
First Name:SERITA
Middle Name:
Last Name:BACKSTRAND
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1791 NW 173RD AVE STE 140
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97006-5630
Mailing Address - Country:US
Mailing Address - Phone:503-533-9806
Mailing Address - Fax:503-352-1809
Practice Address - Street 1:1791 NW 173RD AVE STE 140
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97006
Practice Address - Country:US
Practice Address - Phone:503-533-9806
Practice Address - Fax:503-352-1809
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-21
Last Update Date:2019-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPY60776565103T00000X
OR2933103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR164936Medicaid
OR164936Medicaid