Healthcare Provider Details

I. General information

NPI: 1386001915
Provider Name (Legal Business Name): MARK THOMAS PSYD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/27/2016
Last Update Date: 03/09/2022
Certification Date: 03/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1925 NE STUCKI AVE
HILLSBORO OR
97006-6945
US

IV. Provider business mailing address

23555 NE HIGHWAY 240
NEWBERG OR
97132-7304
US

V. Phone/Fax

Practice location:
  • Phone: 503-906-5019
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number3244
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: