Healthcare Provider Details

I. General information

NPI: 1336043967
Provider Name (Legal Business Name): ANGELA EASTMAN GRISSOM MS, SLP-CCC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/06/2026
Last Update Date: 10/06/2026
Certification Date: 10/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

441 N WERTH BLVD
NEWBERG OR
97132-7500
US

IV. Provider business mailing address

19501 NE HERRING LN
NEWBERG OR
97132-7450
US

V. Phone/Fax

Practice location:
  • Phone: 503-538-9436
  • Fax:
Mailing address:
  • Phone: 510-731-8010
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number12136518
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: