Healthcare Provider Details

I. General information

NPI: 1285914390
Provider Name (Legal Business Name): MARK G. DILLON, PH.D.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/19/2011
Last Update Date: 08/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2720 NE 33RD AVE
PORTLAND OR
97212-3648
US

IV. Provider business mailing address

2720 NE 33RD AVE
PORTLAND OR
97212-3648
US

V. Phone/Fax

Practice location:
  • Phone: 503-281-6162
  • Fax:
Mailing address:
  • Phone: 503-281-6162
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number1722
License Number StateOR

VIII. Authorized Official

Name: DR. MARK GAVIN DILLON
Title or Position: PSYCHOLOGIST
Credential: PH.D.
Phone: 503-281-6162