| Doctor Name: | MR. FREDERICK ELIAS PERSIKO |
| NPI Number: | 1730320557 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | M DIV., CACITI |
| License Number: | 2810 |
| Business Practice Address: | 23400 Two Rivers Road #49 Basalt, CO - 81621 |
| Business Phone Number: | 9709275357 |
| Business Fax Number: | 9709273467 |
| Mailing Address: | P.o. Box 138, BASALT |
| State: | CO |
| Postal Code: | 81621 |
| Phone Number: | 9709275357 |
| Fax Number: | 9709273467 |
| NPI Enumeration Date: | 03/09/2009 |
| NPI Last Update Date: | 03/09/2009 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 101YA0400X |
| License Number: | 2810 |
| Healthcare Provider Taxonomy: (Secondary) | N |
| State: | CO |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Counselor |
| Taxonomy Specialization: | Addiction (Substance Use Disorder) |
| Taxonomy Definition: | |