Healthcare Provider Details

I. General information

NPI: 1396865507
Provider Name (Legal Business Name): JOSEPH MARSHALL CEREGHINO PSY.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/30/2007
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2732 NE BROADWAY ST
PORTLAND OR
97232-1723
US

IV. Provider business mailing address

2732 NE BROADWAY ST
PORTLAND OR
97232-1723
US

V. Phone/Fax

Practice location:
  • Phone: 503-730-8675
  • Fax:
Mailing address:
  • Phone: 503-730-8675
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number1712
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number1712
License Number StateOR
# 3
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number1712
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: