Provider Demographics
NPI:1497818777
Name:CALKINS, RODERICK P (PHD)
Entity Type:Individual
Prefix:
First Name:RODERICK
Middle Name:P
Last Name:CALKINS
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 1:2154 NE BROADWAY ST STE 110
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97232-1561
Mailing Address - Country:US
Mailing Address - Phone:503-320-3059
Mailing Address - Fax:
Practice Address - Street 1:2154 NE BROADWAY ST STE 110
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232-1561
Practice Address - Country:US
Practice Address - Phone:503-320-3059
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-18
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR0867103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR048519Medicaid
OR0000TCHXPMedicare ID - Type UnspecifiedINACTIVE