Healthcare Provider Details

I. General information

NPI: 1548260268
Provider Name (Legal Business Name): CAROL SHYCHY WILLEFORD PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1525 NE WEIDLER ST SUITE 101
PORTLAND OR
97232-1410
US

IV. Provider business mailing address

1525 NE WEIDLER ST SUITE 101
PORTLAND OR
97232-1410
US

V. Phone/Fax

Practice location:
  • Phone: 503-525-1143
  • Fax: 503-287-0212
Mailing address:
  • Phone: 503-525-1143
  • Fax: 503-287-0212

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number080044854N6
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: