Basic Information
| Provider Information | |||||||||
| NPI: | 1144780552 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ALLEN | ||||||||
| FirstName: | ERIC | ||||||||
| MiddleName: | LEE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 912 NE KELLY AVE STE 100 | ||||||||
| Address2: | |||||||||
| City: | GRESHAM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970305631 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5039125502 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 912 NE KELLY AVE | ||||||||
| Address2: | |||||||||
| City: | GRESHAM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970305629 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5039125502 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/21/2019 | ||||||||
| LastUpdateDate: | 03/21/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | OR | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.