Provider Demographics
NPI:1467180323
Name:PARKERSON, ELISSA A
Entity Type:Individual
Prefix:
First Name:ELISSA
Middle Name:A
Last Name:PARKERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ELISSA
Other - Middle Name:A
Other - Last Name:KATEB
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1845
Mailing Address - Street 2:
Mailing Address - City:GOLD BEACH
Mailing Address - State:OR
Mailing Address - Zip Code:97444-1845
Mailing Address - Country:US
Mailing Address - Phone:541-425-5502
Mailing Address - Fax:
Practice Address - Street 1:94166 8TH ST
Practice Address - Street 2:
Practice Address - City:GOLD BEACH
Practice Address - State:OR
Practice Address - Zip Code:97444-7747
Practice Address - Country:US
Practice Address - Phone:541-425-5502
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-09
Last Update Date:2022-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1730689811Medicaid