Provider Demographics
NPI:1164503462
Name:MOFFIT, MARY (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:
Last Name:MOFFIT
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14523 WESTLAKE DR
Mailing Address - Street 2:
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97035-7700
Mailing Address - Country:US
Mailing Address - Phone:503-696-3308
Mailing Address - Fax:503-624-1668
Practice Address - Street 1:14523 WESTLAKE DR
Practice Address - Street 2:
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97035-7700
Practice Address - Country:US
Practice Address - Phone:503-696-3308
Practice Address - Fax:503-624-1668
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1205103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist