Healthcare Provider Details

I. General information

NPI: 1124493580
Provider Name (Legal Business Name): LIFEQUAL, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/09/2015
Last Update Date: 12/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1975 NW 167TH PL
BEAVERTON OR
97006-4908
US

IV. Provider business mailing address

1975 NW 167TH PL
BEAVERTON OR
97006-4908
US

V. Phone/Fax

Practice location:
  • Phone: 503-531-9355
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number1281
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2193
License Number StateOR
# 3
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC169233
License Number StateOR

VIII. Authorized Official

Name: DR. VIJAY SHANKAR
Title or Position: OWNER
Credential: PSY.D.
Phone: 503-531-9355