Healthcare Provider Details

I. General information

NPI: 1770630485
Provider Name (Legal Business Name): CAROL J LANDESMAN PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/04/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8347 SE ORIENT DR
GRESHAM OR
97080-8848
US

IV. Provider business mailing address

8347 SE ORIENT DR
GRESHAM OR
97080-8848
US

V. Phone/Fax

Practice location:
  • Phone: 503-663-7767
  • Fax: 503-663-7274
Mailing address:
  • Phone: 503-663-7767
  • Fax: 503-663-7274

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number858
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: