Provider Demographics
NPI:1831593649
Name:REISBERG, PHILIP C
Entity type:Individual
Prefix:
First Name:PHILIP
Middle Name:C
Last Name:REISBERG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:MENTORED
Other - Middle Name:
Other - Last Name:LEARNING
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:12 SE 14TH AVE.
Mailing Address - Street 2:SUITE 206
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214
Mailing Address - Country:US
Mailing Address - Phone:503-267-8040
Mailing Address - Fax:
Practice Address - Street 1:12 SE 14TH AVE.
Practice Address - Street 2:SUITE 206
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214
Practice Address - Country:US
Practice Address - Phone:503-267-8040
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-22
Last Update Date:2024-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC3561101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional