Healthcare Provider Details

I. General information

NPI: 1477446771
Provider Name (Legal Business Name): FORENSIC NEUROSCIENCE CONSULTANTS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/03/2025
Last Update Date: 06/03/2025
Certification Date: 06/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2030 NW RALEIGH ST
PORTLAND OR
97209-2390
US

IV. Provider business mailing address

2030 NW RALEIGH ST APT 403
PORTLAND OR
97209-2374
US

V. Phone/Fax

Practice location:
  • Phone: 630-935-1548
  • Fax:
Mailing address:
  • Phone: 630-935-1548
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084B0040X
TaxonomyBehavioral Neurology & Neuropsychiatry Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084F0202X
TaxonomyForensic Psychiatry Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2084P0005X
TaxonomyNeurodevelopmental Disabilities Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2084P0802X
TaxonomyAddiction Psychiatry Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code2084P0805X
TaxonomyGeriatric Psychiatry Physician
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: DAVID MASOLAK
Title or Position: OWNER
Credential: MD
Phone: 630-935-1548