Provider Demographics
NPI:1184645871
Name:CHATKUPTLEE, SHARON REBECCA (PSYD)
Entity Type:Individual
Prefix:
First Name:SHARON
Middle Name:REBECCA
Last Name:CHATKUPTLEE
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 1:5410 SW MACADAM AVE
Mailing Address - Street 2:SUITE 230
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239
Mailing Address - Country:US
Mailing Address - Phone:503-963-1290
Mailing Address - Fax:503-230-1541
Practice Address - Street 1:5410 SW MACADAM AVE
Practice Address - Street 2:SUITE 230
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239
Practice Address - Country:US
Practice Address - Phone:503-719-6519
Practice Address - Fax:503-719-6529
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-21
Last Update Date:2010-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1599103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
5610238OtherCCN
054123018OtherBLUE CROSS