MEDICARE: LORAH A SEBASTIAN PHD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	631	OR
2	103T00000X	Psychologist	PY00003429	WA
3	103T00000X	Psychologist	PSY936	HI

General Provider Information

NPI Number	:	1982737532
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LORAH A SEBASTIAN PHD

Provider Business Mailing Address
First Line	:	5441 SW MACADAM
Second Line	:	SUITE 102
City	:	PORTLAND
State	:	OR
Zip	:	97239-3821
Country	:	US
Telephone Number	:	503-221-6946
Fax Number	:	503-222-5480

Provider Business Practice Location Address
First Line	:	5441 SW MACADAM
Second Line	:	SUITE 102
City	:	PORTLAND
State	:	OR
Zip	:	97239-3821
Country	:	US
Telephone Number	:	503-221-6946
Fax Number	:	503-222-5480

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/13/2007
Last Update Date	:	07/08/2007

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