Provider Demographics
NPI:1730320557
Name:PERSIKO, FREDERICK ELIAS (M DIV, CACITI)
Entity type:Individual
Prefix:MR
First Name:FREDERICK
Middle Name:ELIAS
Last Name:PERSIKO
Suffix:
Gender:M
Credentials:M DIV, CACITI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 138
Mailing Address - Street 2:
Mailing Address - City:BASALT
Mailing Address - State:CO
Mailing Address - Zip Code:81621
Mailing Address - Country:US
Mailing Address - Phone:970-927-5357
Mailing Address - Fax:970-927-3467
Practice Address - Street 1:23400 TWO RIVERS ROAD
Practice Address - Street 2:#49
Practice Address - City:BASALT
Practice Address - State:CO
Practice Address - Zip Code:81621
Practice Address - Country:US
Practice Address - Phone:970-927-5357
Practice Address - Fax:970-927-3467
Is Sole Proprietor?:No
Enumeration Date:2009-03-09
Last Update Date:2009-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2810101YA0400X
MI6807010854104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)