Healthcare Provider Details

I. General information

NPI: 1134960248
Provider Name (Legal Business Name): MAIN PSYCHOLOGY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/03/2024
Last Update Date: 06/03/2024
Certification Date: 06/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

502 N MAIN AVE
GRESHAM OR
97030-7236
US

IV. Provider business mailing address

502 N MAIN AVE
GRESHAM OR
97030-7236
US

V. Phone/Fax

Practice location:
  • Phone: 971-328-1794
  • Fax:
Mailing address:
  • Phone: 971-328-1794
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: DEREK NAGY
Title or Position: PRESIDENT
Credential: PHD
Phone: 971-328-1794