Healthcare Provider Details

I. General information

NPI: 1497892145
Provider Name (Legal Business Name): MARY-LYNN THEEL M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/31/2007
Last Update Date: 02/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12250 SW 2ND ST
BEAVERTON OR
97005-2828
US

IV. Provider business mailing address

12250 SW 2ND ST
BEAVERTON OR
97005-2828
US

V. Phone/Fax

Practice location:
  • Phone: 503-906-7481
  • Fax: 503-601-0049
Mailing address:
  • Phone: 503-906-7481
  • Fax: 503-601-0049

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number17319
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: