Provider Demographics
NPI:1174117303
Name:BLACKER, KORIE KERBER
Entity type:Individual
Prefix:
First Name:KORIE
Middle Name:KERBER
Last Name:BLACKER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KORIE
Other - Middle Name:ANN
Other - Last Name:KERBER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:818 COMMERCIAL ST STE 311
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:OR
Mailing Address - Zip Code:97103-4552
Mailing Address - Country:US
Mailing Address - Phone:503-489-8821
Mailing Address - Fax:
Practice Address - Street 1:818 COMMERCIAL ST STE 311
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:OR
Practice Address - Zip Code:97103-4552
Practice Address - Country:US
Practice Address - Phone:503-489-8821
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-28
Last Update Date:2021-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORR6435101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor