Provider Demographics
NPI:1639527575
Name:WRIGHT, RANDALL DAVID (PSYD)
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:DAVID
Last Name:WRIGHT
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 1:5305 RIVER RD N STE B
Mailing Address - Street 2:
Mailing Address - City:KEIZER
Mailing Address - State:OR
Mailing Address - Zip Code:97303-5324
Mailing Address - Country:US
Mailing Address - Phone:510-882-1046
Mailing Address - Fax:
Practice Address - Street 1:1827 NE 44TH AVE STE 320
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-1443
Practice Address - Country:US
Practice Address - Phone:503-477-4969
Practice Address - Fax:503-477-7790
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-01
Last Update Date:2020-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103T00000X
OR3187103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist