Healthcare Provider Details

I. General information

NPI: 1477862142
Provider Name (Legal Business Name): PSYCHMED LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/29/2010
Last Update Date: 09/29/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2354 SE 59TH AVE
PORTLAND OR
97215-4018
US

IV. Provider business mailing address

PO BOX 12745
SALEM OR
97309-0745
US

V. Phone/Fax

Practice location:
  • Phone: 503-516-9308
  • Fax:
Mailing address:
  • Phone: 503-516-9308
  • 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 Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number
License Number State

VIII. Authorized Official

Name: DR. PATRICE D CARRELLO
Title or Position: CLINICAL PSYCHOLOGIST
Credential: PHD
Phone: 503-516-9308