Basic Information
| Provider Information | |||||||||
| NPI: | 1184645871 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHATKUPTLEE | ||||||||
| FirstName: | SHARON | ||||||||
| MiddleName: | REBECCA | ||||||||
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| Credential: | PSYD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5410 SW MACADAM AVE | ||||||||
| Address2: | SUITE 230 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97239 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5039631290 | ||||||||
| FaxNumber: | 5032301541 | ||||||||
| Practice Location | |||||||||
| Address1: | 5410 SW MACADAM AVE | ||||||||
| Address2: | SUITE 230 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97239 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5037196519 | ||||||||
| FaxNumber: | 5037196529 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2006 | ||||||||
| LastUpdateDate: | 06/02/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 1599 | OR | Y | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | 5610238 | 01 | CCN | OTHER | 054123018 | 01 | BLUE CROSS | OTHER |