Provider Demographics
NPI:1689665937
Name:ISAACSON, TERRY (PHD)
Entity Type:Individual
Prefix:DR
First Name:TERRY
Middle Name:
Last Name:ISAACSON
Suffix:
Gender:M
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:PO BOX 1801
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97470-0424
Mailing Address - Country:US
Mailing Address - Phone:541-957-1290
Mailing Address - Fax:541-957-1298
Practice Address - Street 1:1299 NW ELLAN ST STE 3
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97470-2031
Practice Address - Country:US
Practice Address - Phone:541-957-1290
Practice Address - Fax:541-957-1298
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-03
Last Update Date:2010-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR0814103T00000X, 103TC0700X, 103TC1900X, 103TR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR803779000OtherREGENCE BCBSO PROV NO
OR803779000OtherREGENCE BCBSO PROV NO
ORS30224Medicare UPIN