Provider Demographics
NPI:1639907678
Name:KOMMUKURI, SHYAM ABRAHAM
Entity type:Individual
Prefix:
First Name:SHYAM
Middle Name:ABRAHAM
Last Name:KOMMUKURI
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 1:553 NW RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:HAMMOND
Mailing Address - State:OR
Mailing Address - Zip Code:97121-9611
Mailing Address - Country:US
Mailing Address - Phone:443-537-0938
Mailing Address - Fax:
Practice Address - Street 1:7320 SW HUNZIKER RD STE 204
Practice Address - Street 2:
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97223-2301
Practice Address - Country:US
Practice Address - Phone:971-222-8166
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-22
Last Update Date:2024-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC2453101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional