Provider Demographics
NPI:1801222450
Name:SCHMIDT, THEODORE DANIEL (MA)
Entity type:Individual
Prefix:MR
First Name:THEODORE
Middle Name:DANIEL
Last Name:SCHMIDT
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:847 NE 19TH AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97232-2684
Mailing Address - Country:US
Mailing Address - Phone:503-238-0769
Mailing Address - Fax:
Practice Address - Street 1:9911 SE MOUNT SCOTT BLVD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97266
Practice Address - Country:US
Practice Address - Phone:503-258-4300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-15
Last Update Date:2018-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
ORC5018101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health