Healthcare Provider Details

I. General information

NPI: 1942845805
Provider Name (Legal Business Name): I. KEITH ORTON, PHD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/14/2019
Last Update Date: 12/10/2019
Certification Date: 12/10/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

745 NW MT WASHINGTON DR STE 301
BEND OR
97703-1576
US

IV. Provider business mailing address

745 NW MT WASHINGTON DR STE 301
BEND OR
97703-1576
US

V. Phone/Fax

Practice location:
  • Phone: 541-526-1461
  • Fax: 541-678-5513
Mailing address:
  • Phone: 541-526-1461
  • Fax: 541-678-5513

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: IRVING KEITH ORTON
Title or Position: PSYCHOLOGIST
Credential: PHD
Phone: 541-526-1461