Healthcare Provider Details

I. General information

NPI: 1245662741
Provider Name (Legal Business Name): MARTIN BRIAN FISHER JR. PSYD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/06/2013
Last Update Date: 07/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1215 SW 18TH AVE SUITE 4
PORTLAND OR
97205-1711
US

IV. Provider business mailing address

2420 SE TAYLOR ST
PORTLAND OR
97214-2858
US

V. Phone/Fax

Practice location:
  • Phone: 503-318-3236
  • Fax:
Mailing address:
  • Phone: 503-318-3236
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number2383
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code103TA0700X
TaxonomyAdult Development & Aging Psychologist
License Number2383
License Number StateOR
# 3
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number2383
License Number StateOR
# 4
Primary TaxonomyN
Taxonomy Code103TF0000X
TaxonomyFamily Psychologist
License Number2383
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: