Basic Information
| Provider Information | |||||||||
| NPI: | 1295127637 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VILLEGAS-GUTIERREZ | ||||||||
| FirstName: | MARTHA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PH.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 516 SE MORRISON ST STE 221 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972142342 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5037027558 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 12636 SE STARK ST BLDG J | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972331058 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032534609 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/23/2015 | ||||||||
| LastUpdateDate: | 03/29/2018 | ||||||||
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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 | 103TC0700X | 2027 | OR | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 0000WDBCH | 01 | OR | MEDICARE | OTHER | 164936 | 05 | OR | MEDICAID |