Provider Demographics
NPI:1174813539
Name:ROBERT W MCLELLARN, PHD
Entity Type:Organization
Organization Name:ROBERT W MCLELLARN, PHD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:MCLELLARN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:971-645-0033
Mailing Address - Street 1:5440 SW WESTGATE DRIVE
Mailing Address - Street 2:SUITE 175
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97221
Mailing Address - Country:US
Mailing Address - Phone:971-645-0033
Mailing Address - Fax:503-297-5744
Practice Address - Street 1:5440 SW WESTGATE DRIVE
Practice Address - Street 2:SUITE 175
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97221
Practice Address - Country:US
Practice Address - Phone:971-645-0033
Practice Address - Fax:503-297-5744
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-19
Last Update Date:2015-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR634103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & BehavioralGroup - Single Specialty