Basic Information
| Provider Information | |||||||||
| NPI: | 1164820478 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NEUROPSYCHOLOGICAL SERVICES OF OREGON, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 231 SW SCALEHOUSE LOOP STE 203 | ||||||||
| Address2: | |||||||||
| City: | BEND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977021277 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413066456 | ||||||||
| FaxNumber: | 5416471580 | ||||||||
| Practice Location | |||||||||
| Address1: | 231 SW SCALEHOUSE LOOP STE 203 | ||||||||
| Address2: | |||||||||
| City: | BEND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977021277 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413066456 | ||||||||
| FaxNumber: | 5416471580 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/18/2014 | ||||||||
| LastUpdateDate: | 10/17/2018 | ||||||||
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| AuthorizedOfficialLastName: | KREILING | ||||||||
| AuthorizedOfficialFirstName: | TRACY | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5413066456 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | PSY.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 2524 | OR | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | 103G00000X | 2524 | OR | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Clinical Neuropsychologist |
No ID Information.