Provider Demographics
NPI:1760544571
Name:GETZLAF, SHELLY BERNARD (PHD)
Entity Type:Individual
Prefix:DR
First Name:SHELLY
Middle Name:BERNARD
Last Name:GETZLAF
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1017 SW MORRISON ST
Mailing Address - Street 2:STE 411
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97205-2629
Mailing Address - Country:US
Mailing Address - Phone:503-646-4664
Mailing Address - Fax:503-521-7041
Practice Address - Street 1:1017 SW MORRISON ST
Practice Address - Street 2:STE 411
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97205-2629
Practice Address - Country:US
Practice Address - Phone:503-646-4664
Practice Address - Fax:503-521-7041
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-15
Last Update Date:2018-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR717103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR000476Medicaid
OR000476Medicaid