Provider Demographics
NPI:1326042169
Name:AUGUST, MARY KAY (PHD)
Entity Type:Individual
Prefix:
First Name:MARY KAY
Middle Name:
Last Name:AUGUST
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 1:10200 NW ALDER GROVE LN
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97229-7584
Mailing Address - Country:US
Mailing Address - Phone:240-409-5798
Mailing Address - Fax:
Practice Address - Street 1:10200 NW ALDER GROVE LN
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97229-7584
Practice Address - Country:US
Practice Address - Phone:240-409-5798
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD02183103T00000X
OR1810103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD48341OtherMAMSI
MDD262Medicare ID - Type UnspecifiedMEDICARE