Provider Demographics
NPI:1134797475
Name:WATSON, KIRI STORM
Entity type:Individual
Prefix:
First Name:KIRI
Middle Name:STORM
Last Name:WATSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1865 TURNAGE ST NW
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97304-3516
Mailing Address - Country:US
Mailing Address - Phone:503-949-5940
Mailing Address - Fax:
Practice Address - Street 1:4080 REED RD SE STE 150
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-1335
Practice Address - Country:US
Practice Address - Phone:503-581-1732
Practice Address - Fax:503-363-4607
Is Sole Proprietor?:No
Enumeration Date:2021-06-14
Last Update Date:2022-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORTHW000104493175T00000X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No175T00000XOther Service ProvidersPeer Specialist