Provider Demographics
NPI:1245662741
Name:FISHER, MARTIN BRIAN JR (PSYD)
Entity type:Individual
Prefix:
First Name:MARTIN
Middle Name:BRIAN
Last Name:FISHER
Suffix:JR
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 1:2420 SE TAYLOR ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-2858
Mailing Address - Country:US
Mailing Address - Phone:503-318-3236
Mailing Address - Fax:
Practice Address - Street 1:1215 SW 18TH AVE
Practice Address - Street 2:SUITE 4
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97205-1711
Practice Address - Country:US
Practice Address - Phone:503-318-3236
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-06
Last Update Date:2014-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2383103TC0700X, 103TA0700X, 103TC2200X, 103TF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & Aging
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily