Provider Demographics
NPI:1033386339
Name:WOLLERT, RICHARD WALTER (PHD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:WALTER
Last Name:WOLLERT
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1220 SW MORRISON ST STE 930
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97205-2228
Mailing Address - Country:US
Mailing Address - Phone:360-737-7712
Mailing Address - Fax:503-241-7971
Practice Address - Street 1:1220 SW MORRISON ST STE 930
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97205-2228
Practice Address - Country:US
Practice Address - Phone:360-737-7712
Practice Address - Fax:503-241-7971
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-15
Last Update Date:2008-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR795103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical