Healthcare Provider Details

I. General information

NPI: 1376526699
Provider Name (Legal Business Name): MARK R WEINROTT PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 11/21/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5520 SW MACADAM AVE SUITE 260
PORTLAND OR
97239-3768
US

IV. Provider business mailing address

5520 SW MACADAM AVE SUITE 260
PORTLAND OR
97239-3768
US

V. Phone/Fax

Practice location:
  • Phone: 503-221-0368
  • Fax: 503-223-6492
Mailing address:
  • Phone: 503-221-0368
  • Fax: 503-223-6492

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number698
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: