Healthcare Provider Details

I. General information

NPI: 1720496730
Provider Name (Legal Business Name): CHARLES R OBANNON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/23/2014
Last Update Date: 09/25/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31090 SE DIVISION DR
TROUTDALE OR
97060-9451
US

IV. Provider business mailing address

31090 SE DIVISION DR
TROUTDALE OR
97060-9451
US

V. Phone/Fax

Practice location:
  • Phone: 503-618-8041
  • Fax: 503-618-8052
Mailing address:
  • Phone: 503-618-8041
  • Fax: 503-618-8052

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State

VIII. Authorized Official

Name: DR. CHARLES RICHARD O'BANNON
Title or Position: LICENSED PSYCHOLOGIST / OWNER
Credential: PH.D.
Phone: 503-618-8041