Healthcare Provider Details

I. General information

NPI: 1518107226
Provider Name (Legal Business Name): DOUG R ALTILIO PSYD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/20/2009
Last Update Date: 01/02/2024
Certification Date: 01/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2951 NW DIVISION ST STE 200
GRESHAM OR
97030-5294
US

IV. Provider business mailing address

1500 NW BETHANY BLVD STE 320
BEAVERTON OR
97006-5238
US

V. Phone/Fax

Practice location:
  • Phone: 503-258-4600
  • Fax:
Mailing address:
  • Phone: 503-567-3260
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number2465
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: