Provider Demographics
NPI:1346368214
Name:EDELSTEIN, ROBERT ALAN (LMFT, MFT)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:ALAN
Last Name:EDELSTEIN
Suffix:
Gender:M
Credentials:LMFT, MFT
Other - Prefix:
Other - First Name:BOB
Other - Middle Name:
Other - Last Name:EDELSTEIN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMFT, MFT
Mailing Address - Street 1:1804 NE 45TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97213-1416
Mailing Address - Country:US
Mailing Address - Phone:503-288-3967
Mailing Address - Fax:
Practice Address - Street 1:1804 NE 45TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-1416
Practice Address - Country:US
Practice Address - Phone:503-288-3967
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORT0015106H00000X
CAMFC18829106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist