Provider Demographics
NPI:1902013345
Name:GOLDEN, DOUGLAS B (PHD)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:B
Last Name:GOLDEN
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 1:3434 SW KELLY AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-4630
Mailing Address - Country:US
Mailing Address - Phone:503-228-6071
Mailing Address - Fax:
Practice Address - Street 1:3434 SW KELLY AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-4630
Practice Address - Country:US
Practice Address - Phone:503-228-6071
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR391103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical