Provider Demographics
NPI:1043239320
Name:BASHAM, ROBERT BRADLEY (PHD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:BRADLEY
Last Name:BASHAM
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 1:1312 SW 16TH AVENUE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97201-2620
Mailing Address - Country:US
Mailing Address - Phone:503-242-2533
Mailing Address - Fax:503-220-8860
Practice Address - Street 1:1312 SW 16TH AVENUE
Practice Address - Street 2:SUITE 102
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97201-2620
Practice Address - Country:US
Practice Address - Phone:503-242-2533
Practice Address - Fax:503-220-8860
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2009-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR677103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR172718Medicaid