Healthcare Provider Details

I. General information

NPI: 1528111804
Provider Name (Legal Business Name): DONALD DALE COHEN M.S.W., PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/19/2007
Last Update Date: 02/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

511 SW 10TH AVE STE 604
PORTLAND OR
97205-2707
US

IV. Provider business mailing address

511 SW 10TH AVE STE 604
PORTLAND OR
97205-2707
US

V. Phone/Fax

Practice location:
  • Phone: 503-238-5557
  • Fax: 503-234-7166
Mailing address:
  • Phone: 503-281-9232
  • Fax: 503-234-7166

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number1059
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: