Provider Demographics
NPI:1124079066
Name:GUILLAUMOT, JULIEN J (PHD)
Entity type:Individual
Prefix:
First Name:JULIEN
Middle Name:J
Last Name:GUILLAUMOT
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 NW HARRISON BLVD
Mailing Address - Street 2:STE B-20
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97330-6277
Mailing Address - Country:US
Mailing Address - Phone:541-257-5533
Mailing Address - Fax:
Practice Address - Street 1:408 SW MONROE AVE STE M210D
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97333-7228
Practice Address - Country:US
Practice Address - Phone:541-257-5533
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2020-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1683103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR278211Medicaid
Q60669Medicare UPIN
OR278211Medicaid