Basic Information
| Provider Information | |||||||||
| NPI: | 1912008178 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WESTERN PSYCHOLOGICAL AND COUNSELING SERVICES PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 82819 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972820819 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032335405 | ||||||||
| FaxNumber: | 5032332696 | ||||||||
| Practice Location | |||||||||
| Address1: | 880 82ND DR | ||||||||
| Address2: | |||||||||
| City: | GLADSTONE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970271803 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5036595515 | ||||||||
| FaxNumber: | 5036591994 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/26/2006 | ||||||||
| LastUpdateDate: | 01/26/2018 | ||||||||
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| AuthorizedOfficialLastName: | ROBERTSON | ||||||||
| AuthorizedOfficialFirstName: | AMANDA | ||||||||
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| AuthorizedOfficialTitleorPosition: | DELEGATED OFFICIAL | ||||||||
| AuthorizedOfficialTelephone: | 5032335405 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YM0800X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YP2500X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Professional | 103TB0200X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Cognitive & Behavioral | 103TC0700X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103TF0200X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Forensic | 104100000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | 1041C0700X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical | 106H00000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 163WP0807X | N | 193200000X MULTI-SPECIALTY GROUP | Nursing Service Providers | Registered Nurse | Psych/Mental Health, Child & Adolescent | 2084P0800X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 101Y00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor |
ID Information
| ID | Type | State | Issuer | Description | 164936 | 05 | OR | MEDICAID |