Provider Demographics
NPI:1275986721
Name:POLIDORI, ERICA BURDETTE
Entity Type:Individual
Prefix:
First Name:ERICA
Middle Name:BURDETTE
Last Name:POLIDORI
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 1:6443 SW BEAVERTON HILLSDALE HWY STE 300
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97221-4210
Mailing Address - Country:US
Mailing Address - Phone:971-301-2239
Mailing Address - Fax:
Practice Address - Street 1:6443 SW BEAVERTON HILLSDALE HWY STE 300
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97221-4210
Practice Address - Country:US
Practice Address - Phone:971-301-2239
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-20
Last Update Date:2020-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103T00000X
OR3232103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist