Basic Information
| Provider Information | |||||||||
| NPI: | 1750753687 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UNIVERSITY PROFESSIONAL SERVICES | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | OHSU INTERCULTURAL PSYCHIATRIC PROGRAM | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2214 LLOYD CENTER | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972321315 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034944222 | ||||||||
| FaxNumber: | 5034946143 | ||||||||
| Practice Location | |||||||||
| Address1: | 2214 LLOYD CENTER | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972321315 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034944222 | ||||||||
| FaxNumber: | 5034946143 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/30/2015 | ||||||||
| LastUpdateDate: | 07/20/2016 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HECKLER | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
| AuthorizedOfficialMiddleName: | M. | ||||||||
| AuthorizedOfficialTitleorPosition: | SR. ASSOC. DEAN FOR CLINICAL PRACT. | ||||||||
| AuthorizedOfficialTelephone: | 5034944481 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | UNIVERSITY PROFESSIONAL SERVICES | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0850X | Y | Ambulatory Health Care Facilities | Clinic/Center | Adult Mental Health |
No ID Information.