Provider Demographics
NPI:1427277896
Name:AUSUBEL, JOAN ELLEN (PHD)
Entity type:Individual
Prefix:DR
First Name:JOAN
Middle Name:ELLEN
Last Name:AUSUBEL
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8205 SE 11TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97202-6535
Mailing Address - Country:US
Mailing Address - Phone:503-232-6153
Mailing Address - Fax:503-232-6157
Practice Address - Street 1:317 SW ALDER ST
Practice Address - Street 2:SUITE 1140
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97204-2547
Practice Address - Country:US
Practice Address - Phone:503-294-2111
Practice Address - Fax:503-525-0752
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-24
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR735103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR735OtherPSYCHOLOGIST LICENSE #
OR106266Medicare PIN
ORR13558Medicare UPIN