Provider Demographics
NPI:1396842217
Name:PACHECO, IDA CATHERINE (PHD)
Entity Type:Individual
Prefix:DR
First Name:IDA
Middle Name:CATHERINE
Last Name:PACHECO
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 298
Mailing Address - Street 2:
Mailing Address - City:ENTERPRISE
Mailing Address - State:OR
Mailing Address - Zip Code:97828-0298
Mailing Address - Country:US
Mailing Address - Phone:541-398-0015
Mailing Address - Fax:541-432-0860
Practice Address - Street 1:103 HIGHWAY 82
Practice Address - Street 2:SUITE 5
Practice Address - City:ENTERPRISE
Practice Address - State:OR
Practice Address - Zip Code:97828-6011
Practice Address - Country:US
Practice Address - Phone:541-398-0015
Practice Address - Fax:541-432-0860
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR716103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR138800Medicaid
OR138800Medicaid