Provider Demographics
NPI:1164704433
Name:PACK-PATTON, DEBORAH KAY (PSYD)
Entity Type:Individual
Prefix:DR
First Name:DEBORAH
Middle Name:KAY
Last Name:PACK-PATTON
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15823 NE 19TH ST
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98684-4517
Mailing Address - Country:US
Mailing Address - Phone:503-657-1254
Mailing Address - Fax:
Practice Address - Street 1:5329 NE MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97211-3237
Practice Address - Country:US
Practice Address - Phone:503-988-5183
Practice Address - Fax:503-988-5182
Is Sole Proprietor?:No
Enumeration Date:2011-09-13
Last Update Date:2016-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2252103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR22959Medicaid
OR22959Medicaid