Healthcare Provider Details

I. General information

NPI: 1306353958
Provider Name (Legal Business Name): MRS. EVAYN TAYLOR HALL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MS. EVAYN TAYLOR ROPER

II. Dates (important events)

Enumeration Date: 01/04/2018
Last Update Date: 05/19/2022
Certification Date: 05/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

912 NE KELLY AVE SUITE 100C
GRESHAM OR
97030
US

IV. Provider business mailing address

912 NE KELLY AVE SUITE 100C
GRESHAM OR
97030
US

V. Phone/Fax

Practice location:
  • Phone: 503-912-5502
  • Fax:
Mailing address:
  • Phone: 503-912-5502
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberABA-IN-10178814
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: