Provider Demographics
NPI:1972846707
Name:KLERONOMOS, MISHA LYNN (PSYD, LPC)
Entity Type:Individual
Prefix:DR
First Name:MISHA
Middle Name:LYNN
Last Name:KLERONOMOS
Suffix:
Gender:F
Credentials:PSYD, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 BELLEVUE ST SE
Mailing Address - Street 2:#225
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-3819
Mailing Address - Country:US
Mailing Address - Phone:971-273-0070
Mailing Address - Fax:
Practice Address - Street 1:700 BELLEVUE ST SE
Practice Address - Street 2:#225
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-3819
Practice Address - Country:US
Practice Address - Phone:971-273-0070
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-29
Last Update Date:2015-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC2575101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional