Provider Demographics
NPI:1578145884
Name:OLDER GROWTH PSYCHOLOGY
Entity Type:Organization
Organization Name:OLDER GROWTH PSYCHOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED PSYCHOLOGIST, OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARC
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:PARKER
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:503-227-3090
Mailing Address - Street 1:PO BOX 83837
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97283-0837
Mailing Address - Country:US
Mailing Address - Phone:503-227-3090
Mailing Address - Fax:971-339-5269
Practice Address - Street 1:917 SW OAK ST STE 218
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97205-2805
Practice Address - Country:US
Practice Address - Phone:503-227-3090
Practice Address - Fax:971-339-5269
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-26
Last Update Date:2021-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty