Provider Demographics
NPI:1588642953
Name:GRETSCH, JOSEPH PETER (PSYD, ABPP, LICENSED)
Entity Type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:PETER
Last Name:GRETSCH
Suffix:
Gender:M
Credentials:PSYD, ABPP, LICENSED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:818 SW 3RD AVE
Mailing Address - Street 2:#148
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97204-2405
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:818 SW 3RD AVE
Practice Address - Street 2:#148
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97204-2405
Practice Address - Country:US
Practice Address - Phone:503-206-1713
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-05
Last Update Date:2012-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPY2060103TB0200X
OR1287103TR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitation