Provider Demographics
NPI:1356460901
Name:GUASTADISEGNI, PAUL EDWARD (PHD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:EDWARD
Last Name:GUASTADISEGNI
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:511 SW 10TH AVE
Mailing Address - Street 2:SUITE 1115
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97205-2732
Mailing Address - Country:US
Mailing Address - Phone:503-223-7766
Mailing Address - Fax:503-223-8844
Practice Address - Street 1:511 SW 10TH AVE
Practice Address - Street 2:SUITE 1115
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97205-2732
Practice Address - Country:US
Practice Address - Phone:503-223-7766
Practice Address - Fax:503-223-8844
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1307103G00000X, 103TC0700X, 103TC2200X, 103TF0200X, 103TM1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Not Answered103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Not Answered103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
Not Answered103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORM39331OtherOREGON VENDOR NUMBER
OR159027Medicaid