Provider Demographics
NPI:1497892145
Name:THEEL, MARY-LYNN (MD)
Entity Type:Individual
Prefix:
First Name:MARY-LYNN
Middle Name:
Last Name:THEEL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12250 SW 2ND ST
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97005-2828
Mailing Address - Country:US
Mailing Address - Phone:503-906-7481
Mailing Address - Fax:503-601-0049
Practice Address - Street 1:12250 SW 2ND ST
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97005-2828
Practice Address - Country:US
Practice Address - Phone:503-906-7481
Practice Address - Fax:503-601-0049
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2014-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR173192084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORF21660Medicare UPIN