Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 102L00000X | Psychologist | 0814 | OR |
N | 103T00000X | Psychologist | 0814 | OR |
Y | 103G00000X | Clinical Psychologist | 0814 | OR |
Y | 103TC0700X | Clinical Psychologist | 0814 | OR |
N | 103TC1900X | Counseling Psychologist | 0814 | OR |
N | 103TR0400X | Rehabilitation Psychologist | 0814 | OR |
NPI | 1689665937 |
---|---|
Provider Name | Dr. Terry Isaacson |
First Address | Roseburg, OR 97470-0424 |
Second Address | Roseburg, OR 97470-2031 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 03/11/2005 |
Last Update Date | 16/06/2010 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
803779000 | REGENCE BCBSO PROV NO (01) | OR |
S30224 | (02) | OR |