Provider Demographics
NPI:1528107679
Name:ATKINSON, JOHN D III (PHD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:D
Last Name:ATKINSON
Suffix:III
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 1:3939 NW CLARENCE CIR
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97330-6548
Mailing Address - Country:US
Mailing Address - Phone:541-752-7175
Mailing Address - Fax:541-752-0956
Practice Address - Street 1:744 NW 4TH ST
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97330-6415
Practice Address - Country:US
Practice Address - Phone:541-752-7175
Practice Address - Fax:541-752-0956
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR545103TC2200X, 103TF0000X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Not Answered103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR0000TCJCLMedicare ID - Type UnspecifiedPROVIDER ID NUMBER