Healthcare Provider Details

I. General information

NPI: 1508856642
Provider Name (Legal Business Name): CHARLES RICHARD O'BANNON PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/27/2005
Last Update Date: 10/25/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

123 E POWELL BLVD STE. 212
GRESHAM OR
97030-7622
US

IV. Provider business mailing address

123 E POWELL BLVD STE. 212
GRESHAM OR
97030-7622
US

V. Phone/Fax

Practice location:
  • Phone: 503-618-8041
  • Fax: 503-618-8052
Mailing address:
  • Phone: 503-618-8041
  • Fax: 503-618-8052

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number1044
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: