Provider Demographics
NPI:1265605133
Name:SAMARATUNGE, KUSHANTHI SURINI (PSYD)
Entity type:Individual
Prefix:
First Name:KUSHANTHI
Middle Name:SURINI
Last Name:SAMARATUNGE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7455 SW BEVELAND RD
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97223-8610
Mailing Address - Country:US
Mailing Address - Phone:503-624-2600
Mailing Address - Fax:503-624-7752
Practice Address - Street 1:7455 SW BEVELAND RD
Practice Address - Street 2:
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97223-8610
Practice Address - Country:US
Practice Address - Phone:503-624-2600
Practice Address - Fax:503-624-7752
Is Sole Proprietor?:No
Enumeration Date:2008-04-10
Last Update Date:2015-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2628103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR210855Medicaid