Healthcare Provider Details

I. General information

NPI: 1316533979
Provider Name (Legal Business Name): WILLAMETTE FALLS NEUROPSYCHOLOGY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/17/2020
Last Update Date: 12/17/2020
Certification Date: 12/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

619 MADISON ST STE 108
OREGON CITY OR
97045-2354
US

IV. Provider business mailing address

619 MADISON ST STE 108
OREGON CITY OR
97045-2354
US

V. Phone/Fax

Practice location:
  • Phone: 503-303-4257
  • Fax: 503-387-3957
Mailing address:
  • Phone: 503-303-4257
  • Fax: 503-387-3957

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State

VIII. Authorized Official

Name: DR. LOREN MALLORY
Title or Position: OWNER
Credential: PHD
Phone: 503-303-4257