Provider Demographics
NPI:1295870038
Name:DILLON, MARK GAVIN (PHD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:GAVIN
Last Name:DILLON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2720 NE 33RD AVENUE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97212
Mailing Address - Country:US
Mailing Address - Phone:503-281-6162
Mailing Address - Fax:503-284-1750
Practice Address - Street 1:2720 NE 33RD AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97212-3648
Practice Address - Country:US
Practice Address - Phone:503-281-6162
Practice Address - Fax:503-284-1750
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-20
Last Update Date:2011-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1722103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist