Provider Demographics
NPI:1376694554
Name:WISE, DEBORAH (PH D)
Entity Type:Individual
Prefix:DR
First Name:DEBORAH
Middle Name:
Last Name:WISE
Suffix:
Gender:F
Credentials:PH D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1962 NW KEARNEY ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97209-1400
Mailing Address - Country:US
Mailing Address - Phone:503-381-1871
Mailing Address - Fax:503-222-2136
Practice Address - Street 1:1962 NW KEARNEY ST
Practice Address - Street 2:SUITE 201
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97209-1400
Practice Address - Country:US
Practice Address - Phone:503-381-1871
Practice Address - Fax:503-222-2136
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1669103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical