Healthcare Provider Details

I. General information

NPI: 1487931523
Provider Name (Legal Business Name): INTERCULTURAL CENTER FOR PSYCHOLOGY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/03/2011
Last Update Date: 10/21/2020
Certification Date: 10/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

710C FOOTHILLS DR SUITE 104
NEWBERG OR
97132
US

IV. Provider business mailing address

PO BOX 256
NEWBERG OR
97132-0256
US

V. Phone/Fax

Practice location:
  • Phone: 503-930-2065
  • Fax:
Mailing address:
  • Phone: 503-930-2065
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number1935
License Number StateOR

VIII. Authorized Official

Name: DR. SERGIY BARSUKOV
Title or Position: PSYCHOLOGIST
Credential: PSYD
Phone: 503-930-2065