Provider Demographics
NPI:1063155513
Name:RECK, MARK IRA (PSYD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:IRA
Last Name:RECK
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3178 SW 12TH AVE APT 204
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-3144
Mailing Address - Country:US
Mailing Address - Phone:503-863-1290
Mailing Address - Fax:
Practice Address - Street 1:812 SW WASHINGTON ST STE 700
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97205-3200
Practice Address - Country:US
Practice Address - Phone:503-622-8964
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-13
Last Update Date:2022-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3539103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty