Provider Demographics
NPI:1215093117
Name:KOHEN, MARK H (PSYD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:H
Last Name:KOHEN
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 1:1525 NE WEIDLER ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97232-1410
Mailing Address - Country:US
Mailing Address - Phone:503-287-4975
Mailing Address - Fax:503-287-0212
Practice Address - Street 1:1525 NE WEIDLER ST
Practice Address - Street 2:SUITE 101
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232-1410
Practice Address - Country:US
Practice Address - Phone:503-287-4975
Practice Address - Fax:503-287-0212
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-28
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR0874103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR268052Medicaid