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General NPI Number Information
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NPI Number | 1063155513
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Entity Type | Individual
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Provider Name | MARK IRA RECK PSYD
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Gender | Male
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Dates
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Enumeration Date | 04/13/2022
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Last Update Date | 04/13/2022
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Provider Practice Location Address
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Address Line | 812 SW WASHINGTON ST STE 700
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City | PORTLAND
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State | OR
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Zip | 97205-3200
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Country | US
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Telephone | 503-622-8964
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Fax |
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Provider Business Mailing Address
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Address Line | 3178 SW 12TH AVE APT 204
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City | PORTLAND
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State | OR
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Zip | 97239-3144
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Country | US
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Telephone | 503-863-1290
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 3539
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License Number State | OR
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