Basic Information
| Provider Information | |||||||||
| NPI: | 1497179212 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WESTERN PSYCHOLOGICAL AND COUNSELING SERVICES PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1700 NW CIVIC DR STE 310 | ||||||||
| Address2: | |||||||||
| City: | GRESHAM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970303774 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1700 NW CIVIC DR STE 310 | ||||||||
| Address2: | |||||||||
| City: | GRESHAM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970303774 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5036668832 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/13/2014 | ||||||||
| LastUpdateDate: | 01/26/2018 | ||||||||
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| AuthorizedOfficialLastName: | ROBERTSON | ||||||||
| AuthorizedOfficialFirstName: | AMANDA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CONTRACT AND CREDENTIALING | ||||||||
| AuthorizedOfficialTelephone: | 5032335405 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor |
ID Information
| ID | Type | State | Issuer | Description | 164936 | 05 | OR | MEDICAID |