Healthcare Provider Details

I. General information

NPI: 1245382456
Provider Name (Legal Business Name): MICHAEL J FULOP PSYD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/17/2007
Last Update Date: 09/06/2022
Certification Date: 10/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2130 SW JEFFERSON ST STE 300
PORTLAND OR
97201-7711
US

IV. Provider business mailing address

2130 SW JEFFERSON ST STE 300
PORTLAND OR
97201-7711
US

V. Phone/Fax

Practice location:
  • Phone: 503-539-4932
  • Fax: 503-297-5744
Mailing address:
  • Phone: 503-539-4932
  • Fax: 503-297-5744

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number1049
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: