Provider Demographics
NPI:1265801484
Name:IRVINE, MICHAEL (PSYD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:IRVINE
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 1:8440 SE SUNNYBROOK BLVD STE 120
Mailing Address - Street 2:
Mailing Address - City:CLACKAMAS
Mailing Address - State:OR
Mailing Address - Zip Code:97015-5781
Mailing Address - Country:US
Mailing Address - Phone:503-653-0631
Mailing Address - Fax:503-653-1464
Practice Address - Street 1:8440 SE SUNNYBROOK BLVD STE 120
Practice Address - Street 2:
Practice Address - City:CLACKAMAS
Practice Address - State:OR
Practice Address - Zip Code:97015-5781
Practice Address - Country:US
Practice Address - Phone:503-653-0631
Practice Address - Fax:503-653-1464
Is Sole Proprietor?:No
Enumeration Date:2015-09-17
Last Update Date:2015-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2648103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical