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General NPI Number Information
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NPI Number | 1578145884
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Entity Type | Organization
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Legal Business Name | OLDER GROWTH PSYCHOLOGY
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Dates
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Enumeration Date | 04/26/2021
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Last Update Date | 05/05/2021
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Provider Practice Location Address
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Address Line | 917 SW OAK ST STE 218
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City | PORTLAND
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State | OR
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Zip | 97205-2805
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Country | US
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Telephone | 503-227-3090
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Fax | 971-339-5269
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Provider Business Mailing Address
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Address Line | PO BOX 83837
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City | PORTLAND
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State | OR
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Zip | 97283-0837
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Country | US
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Telephone | 503-227-3090
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Fax | 971-339-5269
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Authorized Official
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Title or Position | LICENSED PSYCHOLOGIST, OWNER
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Name | DR. MARC ROBERT PARKER
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Credential | PSYD
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Telephone | 503-227-3090
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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 |
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License Number State |
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