Provider Demographics
NPI:1881813004
Name:MENTOR PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:MENTOR PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAELE
Authorized Official - Middle Name:P
Authorized Official - Last Name:DUNLAP
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:503-227-2027
Mailing Address - Street 1:818 NW 17TH AVE # 11
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97209-2327
Mailing Address - Country:US
Mailing Address - Phone:503-227-2027
Mailing Address - Fax:503-227-3836
Practice Address - Street 1:818 NW 17TH AVE # 11
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97209-2327
Practice Address - Country:US
Practice Address - Phone:503-227-2027
Practice Address - Fax:503-227-3836
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR0947103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OROOOOWCBBFMedicare ID - Type Unspecified