Provider Demographics
NPI:1700194149
Name:WELCH-PEMBERTON, VANESSA MARIE (PSY D)
Entity Type:Individual
Prefix:
First Name:VANESSA
Middle Name:MARIE
Last Name:WELCH-PEMBERTON
Suffix:
Gender:F
Credentials:PSY D
Other - Prefix:
Other - First Name:VANESSA
Other - Middle Name:MARIE
Other - Last Name:WELCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA
Mailing Address - Street 1:800 SW 13TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97205
Mailing Address - Country:US
Mailing Address - Phone:503-221-0161
Mailing Address - Fax:
Practice Address - Street 1:5005 NE SANDY BLVD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213
Practice Address - Country:US
Practice Address - Phone:503-233-6940
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-20
Last Update Date:2023-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPY60248926103TC0700X
OR2918103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical