Provider Demographics
NPI:1619913787
Name:PORTLAND DIALECTICAL BEHAVIOR THERAPY PC
Entity Type:Organization
Organization Name:PORTLAND DIALECTICAL BEHAVIOR THERAPY PC
Other - Org Name:PORTLAND DBT PROGRAM
Other - Org Type:Other Name
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:AMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTINSON
Authorized Official - Suffix:
Authorized Official - Credentials:BS
Authorized Official - Phone:503-231-7854
Mailing Address - Street 1:5200 SW MACADAM AVE
Mailing Address - Street 2:STE 580
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239
Mailing Address - Country:US
Mailing Address - Phone:503-231-7854
Mailing Address - Fax:503-231-8153
Practice Address - Street 1:5200 SW MACADAM AVE
Practice Address - Street 2:STE 580
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239
Practice Address - Country:US
Practice Address - Phone:503-231-7854
Practice Address - Fax:503-231-8153
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-20
Last Update Date:2008-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & BehavioralGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR240095Medicaid
OR136771Medicare PIN