Provider Demographics
NPI:1275866626
Name:BERMEOSOLO, HEIDI (LPC)
Entity Type:Individual
Prefix:
First Name:HEIDI
Middle Name:
Last Name:BERMEOSOLO
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8007 NE 61ST ST
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98662-5467
Mailing Address - Country:US
Mailing Address - Phone:503-349-1362
Mailing Address - Fax:
Practice Address - Street 1:1700 NW CIVIC DR STE 310
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-3774
Practice Address - Country:US
Practice Address - Phone:503-666-8832
Practice Address - Fax:503-666-8832
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-16
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X, 171M00000X
ORC3069101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171M00000XOther Service ProvidersCase Manager/Care Coordinator