Healthcare Provider Details

I. General information

NPI: 1063375368
Provider Name (Legal Business Name): HOLLY JUNE ALTIERO PHD, PCA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/04/2025
Last Update Date: 12/04/2025
Certification Date: 12/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14764 SE WANDA DR
PORTLAND OR
97267-3112
US

IV. Provider business mailing address

272 NW MEDICAL LOOP STE ROSEBURG
ROSEBURG OR
97471-5597
US

V. Phone/Fax

Practice location:
  • Phone: 971-266-9445
  • Fax:
Mailing address:
  • Phone: 541-900-4285
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberR12344
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: