Provider Demographics
NPI:1376932897
Name:DERKSEN, KRISTINA LOUISE (PEER SUPPORT)
Entity Type:Individual
Prefix:
First Name:KRISTINA
Middle Name:LOUISE
Last Name:DERKSEN
Suffix:
Gender:F
Credentials:PEER SUPPORT
Other - Prefix:
Other - First Name:KRISTINA
Other - Middle Name:LOUISE
Other - Last Name:SAMARA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2577 NE COURTNEY DR
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-7752
Mailing Address - Country:US
Mailing Address - Phone:541-322-7500
Mailing Address - Fax:541-322-7565
Practice Address - Street 1:2577 NE COURTNEY DR
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-7752
Practice Address - Country:US
Practice Address - Phone:541-322-7500
Practice Address - Fax:541-322-7565
Is Sole Proprietor?:No
Enumeration Date:2015-01-21
Last Update Date:2020-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health