Provider Demographics
NPI:1184615288
Name:QUACKENBUSH, ROSS ALLEN (PSYD)
Entity type:Individual
Prefix:DR
First Name:ROSS
Middle Name:ALLEN
Last Name:QUACKENBUSH
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 1:2493 STATE ST
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-4543
Mailing Address - Country:US
Mailing Address - Phone:503-588-1010
Mailing Address - Fax:503-588-9424
Practice Address - Street 1:2493 STATE ST
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-4543
Practice Address - Country:US
Practice Address - Phone:503-588-1010
Practice Address - Fax:503-588-9424
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1140103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical