Provider Demographics
NPI:1821347535
Name:PERSICO, EMILY CATHERINE (MC)
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:CATHERINE
Last Name:PERSICO
Suffix:
Gender:F
Credentials:MC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15330 SE YAMHILL ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97233-2953
Mailing Address - Country:US
Mailing Address - Phone:503-200-7346
Mailing Address - Fax:
Practice Address - Street 1:11456 NE KNOTT ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97220-1706
Practice Address - Country:US
Practice Address - Phone:503-736-6671
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-10
Last Update Date:2022-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORR3493101YM0800X
ORC6219101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health