Healthcare Provider Details

I. General information

NPI: 1538315015
Provider Name (Legal Business Name): COURTNEY ANN MCCALLUM APRN PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/15/2008
Last Update Date: 05/02/2024
Certification Date: 05/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14305 SW 112TH AVE
PORTLAND OR
97224-3705
US

IV. Provider business mailing address

14305 SW 112TH AVE
PORTLAND OR
97224-3705
US

V. Phone/Fax

Practice location:
  • Phone: 503-660-2418
  • Fax:
Mailing address:
  • Phone: 503-660-2418
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License Number200841828RN
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number10025683
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: