Provider Demographics
NPI:1205237294
Name:PEHLKE, KERKULA JT
Entity type:Individual
Prefix:
First Name:KERKULA
Middle Name:JT
Last Name:PEHLKE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1222 E 8TH ST
Mailing Address - Street 2:
Mailing Address - City:THE DALLES
Mailing Address - State:OR
Mailing Address - Zip Code:97058-2914
Mailing Address - Country:US
Mailing Address - Phone:360-901-6274
Mailing Address - Fax:
Practice Address - Street 1:419 E 7TH ST STE 207
Practice Address - Street 2:
Practice Address - City:THE DALLES
Practice Address - State:OR
Practice Address - Zip Code:97058-2676
Practice Address - Country:US
Practice Address - Phone:541-296-5452
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-09
Last Update Date:2014-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health