=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962781542
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DERRIN YOSHIO KILIPAKI FUKUDA PSY.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/12/2011
-----------------------------------------------------
Last Update Date | 09/30/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 516 SE MORRISON ST STE 400
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97214-2344
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 971-242-8894
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 516 SE MORRISON ST STE 400
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97214-2344
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 971-242-8894
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC2200X
-----------------------------------------------------
Taxonomy Name | Clinical Child & Adolescent Psychologist
-----------------------------------------------------
License Number | 2399
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------