Healthcare Provider Details

I. General information

NPI: 1578637096
Provider Name (Legal Business Name): SPEECH PATHOLOGY ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/17/2006
Last Update Date: 07/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5905 SE POWELL VALLEY RD
GRESHAM OR
97080-1919
US

IV. Provider business mailing address

PO BOX 82608
PORTLAND OR
97282-0608
US

V. Phone/Fax

Practice location:
  • Phone: 503-665-1151
  • Fax: 503-669-1986
Mailing address:
  • Phone: 503-665-1151
  • Fax: 503-669-1986

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number10394
License Number StateOR

VIII. Authorized Official

Name: BLAISE SCOLLARD
Title or Position: OWNER
Credential:
Phone: 503-665-1151