Provider Demographics
NPI:1356003438
Name:SHETTY, AMALA (PHD)
Entity Type:Individual
Prefix:
First Name:AMALA
Middle Name:
Last Name:SHETTY
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 1:520 SW YAMHILL ST STE 428
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97204-1327
Mailing Address - Country:US
Mailing Address - Phone:503-946-9036
Mailing Address - Fax:
Practice Address - Street 1:520 SW YAMHILL ST STE 428
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97204-1327
Practice Address - Country:US
Practice Address - Phone:503-946-9036
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-06
Last Update Date:2021-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3117103TF0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic