Healthcare Provider Details

I. General information

NPI: 1215468665
Provider Name (Legal Business Name): WESTERN PSYCHOLOGICAL AND COUNSELING SERVICES PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/27/2017
Last Update Date: 01/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2222 E POWELL BLVD
GRESHAM OR
97080-1365
US

IV. Provider business mailing address

PO BOX 82819
PORTLAND OR
97282
US

V. Phone/Fax

Practice location:
  • Phone: 503-669-4300
  • Fax: 503-669-4301
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: AMANDA ROBERTSON
Title or Position: CONTRACT AND CREDENTIALING
Credential:
Phone: 503-233-5405