Provider Demographics
NPI:1437131646
Name:HARRISON, CHARLES WAY (PHD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:WAY
Last Name:HARRISON
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:PO BOX 17658
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97217-0658
Mailing Address - Country:US
Mailing Address - Phone:503-975-0014
Mailing Address - Fax:503-283-7085
Practice Address - Street 1:1210 SE OAK ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214-1427
Practice Address - Country:US
Practice Address - Phone:503-975-0014
Practice Address - Fax:503-283-7085
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-15
Last Update Date:2015-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1148103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500612148Medicaid
OR150873Medicaid