Provider Demographics
NPI:1194854562
Name:MCCLURE, DOUGLAS G (PSYD)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:G
Last Name:MCCLURE
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15880 QUARRY RD
Mailing Address - Street 2:
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97035-3336
Mailing Address - Country:US
Mailing Address - Phone:503-697-1800
Mailing Address - Fax:503-228-7197
Practice Address - Street 1:15880 QUARRY RD
Practice Address - Street 2:
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97035-3336
Practice Address - Country:US
Practice Address - Phone:503-697-1800
Practice Address - Fax:503-228-7197
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1313103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR130548Medicare ID - Type Unspecified