Individual
MYCO VAN
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
PSY.D.
Contact information
Practice address
1500 NE IRVING ST, SUITE 250, PORTLAND, OR 97232-2243
(503) 233-4356
Mailing address
8401 NE HALSEY ST STE 203, PORTLAND, OR 97220-5670
(503) 867-2289
Taxonomy
Speciality
Code
Description
License number
State
103TC0700X
Clinical Psychologist
Primary
1791
OR
Other
Enumeration date
02/21/2007
Last updated
11/07/2009
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