Healthcare Provider Details

I. General information

NPI: 1356538847
Provider Name (Legal Business Name): SERGIY BARSUKOV PSYD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/27/2007
Last Update Date: 03/09/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

502 S SAINT PAUL HWY
NEWBERG OR
97132-7059
US

IV. Provider business mailing address

PO BOX 256
NEWBERG OR
97132-0256
US

V. Phone/Fax

Practice location:
  • Phone: 503-949-4961
  • Fax:
Mailing address:
  • Phone: 503-949-4961
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number1935
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: