Provider Demographics
NPI:1346254083
Name:EMERSON, JUDITH (PHD)
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:
Last Name:EMERSON
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 1:1675 SW MARLOW AVE
Mailing Address - Street 2:SUITE 210G
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97225-5104
Mailing Address - Country:US
Mailing Address - Phone:503-989-6172
Mailing Address - Fax:
Practice Address - Street 1:1675 SW MARLOW AVE
Practice Address - Street 2:SUITE 210G
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-5104
Practice Address - Country:US
Practice Address - Phone:503-989-6172
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-28
Last Update Date:2014-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR0981103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR168884OtherMEDICARE PTAN