Provider Demographics
NPI:1710205232
Name:QUISENBERRY, CLINTON EDWARD (PHD)
Entity type:Individual
Prefix:DR
First Name:CLINTON
Middle Name:EDWARD
Last Name:QUISENBERRY
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 1:7505 SW BEVELAND RD
Mailing Address - Street 2:STE 102
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97223-8682
Mailing Address - Country:US
Mailing Address - Phone:503-747-4646
Mailing Address - Fax:503-214-8668
Practice Address - Street 1:7505 SW BEVELAND RD
Practice Address - Street 2:STE 102
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97223-8682
Practice Address - Country:US
Practice Address - Phone:503-747-4646
Practice Address - Fax:503-214-8668
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-07
Last Update Date:2024-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPY60132400103T00000X, 103T00000X
OR2721103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist