Provider Demographics
NPI:1245526573
Name:SHAHABUDDIN, AMBREEN (PHD)
Entity type:Individual
Prefix:DR
First Name:AMBREEN
Middle Name:
Last Name:SHAHABUDDIN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3720 SW BOND AVE UNIT 710
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-4573
Mailing Address - Country:US
Mailing Address - Phone:775-815-6691
Mailing Address - Fax:
Practice Address - Street 1:707 SW GAINES ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239
Practice Address - Country:US
Practice Address - Phone:503-494-2155
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-24
Last Update Date:2019-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3159103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical