Provider Demographics
NPI:1518107226
Name:ALTILIO, DOUG R (PSYD)
Entity Type:Individual
Prefix:MR
First Name:DOUG
Middle Name:R
Last Name:ALTILIO
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 NW BETHANY BLVD STE 320
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97006-5238
Mailing Address - Country:US
Mailing Address - Phone:503-567-3260
Mailing Address - Fax:
Practice Address - Street 1:2951 NW DIVISION ST STE 200
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-5294
Practice Address - Country:US
Practice Address - Phone:503-258-4600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-02-20
Last Update Date:2024-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2465103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist