Healthcare Provider Details

I. General information

NPI: 1437215712
Provider Name (Legal Business Name): PATRICE DEIDRE CARRELLO PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/29/2006
Last Update Date: 07/28/2026
Certification Date: 07/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 NE BROADWAY ST STE 323
PORTLAND OR
97232-1570
US

IV. Provider business mailing address

2354 SE 59TH AVE
PORTLAND OR
97215-4018
US

V. Phone/Fax

Practice location:
  • Phone: 541-500-8655
  • Fax:
Mailing address:
  • Phone: 541-500-8655
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number1626
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: