MEDICARE: DR. STANDISH MCCLEARY III PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	0970	OR

General Provider Information

NPI Number	:	1194857789
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. STANDISH MCCLEARY III PH.D.

Provider Business Mailing Address
First Line	:	2188 SW PARK PL
Second Line	:	SUITE 200
City	:	PORTLAND
State	:	OR
Zip	:	97205-1100
Country	:	US
Telephone Number	:	503-228-0688
Fax Number	:	503-203-1023

Provider Business Practice Location Address
First Line	:	2188 SW PARK PL
Second Line	:	SUITE 200
City	:	PORTLAND
State	:	OR
Zip	:	97205-1100
Country	:	US
Telephone Number	:	503-228-0688
Fax Number	:	503-203-1023

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/10/2007
Last Update Date	:	07/08/2007

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