Basic Information
| Provider Information | |||||||||
| NPI: | 1912377193 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PACIFIC UNIVERSITY | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | PACIFIC PSYCHOLOGY & COMPREHENSIVE HEALTH CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1411 SW MORRISON ST | ||||||||
| Address2: | SUTIE 310 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972051945 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5033522400 | ||||||||
| FaxNumber: | 5033522403 | ||||||||
| Practice Location | |||||||||
| Address1: | 1411 SW MORRISON ST | ||||||||
| Address2: | SUTIE 310 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972051945 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5033522400 | ||||||||
| FaxNumber: | 5033522403 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/01/2015 | ||||||||
| LastUpdateDate: | 10/28/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MONAHAN | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OPERATIONS MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 5033522404 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0855X | 1476 | OR | N | Ambulatory Health Care Facilities | Clinic/Center | Adolescent and Children Mental Health | 261QM0850X | 1476 | OR | Y | Ambulatory Health Care Facilities | Clinic/Center | Adult Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 500694103 | 05 | OR | MEDICAID |