Provider Demographics
NPI:1154479665
Name:COOLEY, NORVIN R (PHD)
Entity Type:Individual
Prefix:
First Name:NORVIN
Middle Name:R
Last Name:COOLEY
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:JAKE
Other - Middle Name:
Other - Last Name:COOLEY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:610 JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:OREGON CITY
Mailing Address - State:OR
Mailing Address - Zip Code:97045
Mailing Address - Country:US
Mailing Address - Phone:503-657-7235
Mailing Address - Fax:503-657-7676
Practice Address - Street 1:610 JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:OREGON CITY
Practice Address - State:OR
Practice Address - Zip Code:97045
Practice Address - Country:US
Practice Address - Phone:503-657-7235
Practice Address - Fax:503-657-7676
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR0453103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR224584Medicaid
117714OtherMHN HMC
R94189Medicare UPIN
117714OtherMHN HMC