Healthcare Provider Details

I. General information

NPI: 1316749575
Provider Name (Legal Business Name): CHELISA MARIA DEANDA-HESCOCK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/26/2025
Last Update Date: 03/26/2025
Certification Date: 03/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1851 NW CIVIC DR
GRESHAM OR
97030-5566
US

IV. Provider business mailing address

38900 SE TUMALA MOUNTAIN RD
ESTACADA OR
97023-7444
US

V. Phone/Fax

Practice location:
  • Phone: 971-292-1050
  • Fax:
Mailing address:
  • Phone: 971-645-8197
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: