Healthcare Provider Details

I. General information

NPI: 1720834187
Provider Name (Legal Business Name): THEODORE VOSSEN SLP
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/26/2024
Last Update Date: 04/26/2024
Certification Date: 04/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

505 SW BIRDSDALE DR
GRESHAM OR
97080-6747
US

IV. Provider business mailing address

505 SW BIRDSDALE DR
GRESHAM OR
97080-6747
US

V. Phone/Fax

Practice location:
  • Phone: 503-661-6226
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number015448
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: