Provider Demographics
NPI:1417963745
Name:ROSENBERG, RICHARD JAY (PHD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:JAY
Last Name:ROSENBERG
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 1:3426 NE 19TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97212-2407
Mailing Address - Country:US
Mailing Address - Phone:503-402-1802
Mailing Address - Fax:503-402-1802
Practice Address - Street 1:2161 NE BROADWAY ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232-1512
Practice Address - Country:US
Practice Address - Phone:503-402-1802
Practice Address - Fax:503-402-1802
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2011-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR500103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical