Provider Demographics
NPI:1295127637
Name:VILLEGAS-GUTIERREZ, MARTHA (PHD)
Entity type:Individual
Prefix:DR
First Name:MARTHA
Middle Name:
Last Name:VILLEGAS-GUTIERREZ
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 1:516 SE MORRISON ST STE 221
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-2342
Mailing Address - Country:US
Mailing Address - Phone:503-702-7558
Mailing Address - Fax:
Practice Address - Street 1:12636 SE STARK ST BLDG J
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97233-1058
Practice Address - Country:US
Practice Address - Phone:503-253-4609
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-23
Last Update Date:2018-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2027103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR0000WDBCHOtherMEDICARE
OR164936Medicaid