Provider Demographics
NPI:1720687809
Name:GREGORY, KARISSA MYRIAH
Entity Type:Individual
Prefix:
First Name:KARISSA
Middle Name:MYRIAH
Last Name:GREGORY
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 1:9620 NE TANASBOURNE DR STE 300
Mailing Address - Street 2:
Mailing Address - City:HILLSBORO
Mailing Address - State:OR
Mailing Address - Zip Code:97124-7844
Mailing Address - Country:US
Mailing Address - Phone:541-818-0009
Mailing Address - Fax:
Practice Address - Street 1:9620 NE TANASBOURNE DR STE 300
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:OR
Practice Address - Zip Code:97124-7844
Practice Address - Country:US
Practice Address - Phone:541-818-0009
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-20
Last Update Date:2022-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty