Provider Demographics
NPI:1558425926
Name:RICHARDSON, PHYLLIS M (PHD)
Entity Type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:M
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1112 NE 21ST AVE
Mailing Address - Street 2:SUITE 5
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97232
Mailing Address - Country:US
Mailing Address - Phone:503-281-1897
Mailing Address - Fax:503-281-4862
Practice Address - Street 1:1112 NE 21ST AVE
Practice Address - Street 2:SUITE 5
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232-2595
Practice Address - Country:US
Practice Address - Phone:503-281-1897
Practice Address - Fax:503-281-4862
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-20
Last Update Date:2007-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR668103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR164936Medicaid
OR164936Medicaid