Healthcare Provider Details

I. General information

NPI: 1518203603
Provider Name (Legal Business Name): PACIFIC PSYCHOLOGY GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/18/2012
Last Update Date: 12/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

502 N MAIN AVE
GRESHAM OR
97030-7236
US

IV. Provider business mailing address

502 N MAIN AVE
GRESHAM OR
97030-7236
US

V. Phone/Fax

Practice location:
  • Phone: 503-492-7470
  • Fax: 503-492-0939
Mailing address:
  • Phone: 503-492-7470
  • Fax: 503-492-0939

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number792
License Number StateOR

VIII. Authorized Official

Name: GREGORY MORSE
Title or Position: PSY.D.
Credential:
Phone: 503-492-7470