Provider Demographics
NPI:1992258958
Name:PEREZ-MEDINA, ALEXIS LLEMAL (MA)
Entity type:Individual
Prefix:MR
First Name:ALEXIS
Middle Name:LLEMAL
Last Name:PEREZ-MEDINA
Suffix:
Gender:M
Credentials:MA
Other - Prefix:MR
Other - First Name:ALEX
Other - Middle Name:
Other - Last Name:PEREZ
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:906 MAIN AVE
Mailing Address - Street 2:
Mailing Address - City:TILLAMOOK
Mailing Address - State:OR
Mailing Address - Zip Code:97141-3816
Mailing Address - Country:US
Mailing Address - Phone:503-842-8201
Mailing Address - Fax:503-815-1870
Practice Address - Street 1:906 MAIN AVE
Practice Address - Street 2:
Practice Address - City:TILLAMOOK
Practice Address - State:OR
Practice Address - Zip Code:97141-3816
Practice Address - Country:US
Practice Address - Phone:503-842-8201
Practice Address - Fax:503-815-1870
Is Sole Proprietor?:No
Enumeration Date:2016-07-26
Last Update Date:2019-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
OR101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500714618Medicaid