Healthcare Provider Details

I. General information

NPI: 1598057689
Provider Name (Legal Business Name): LINDSAY KAYE TICE PSY D
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/06/2011
Last Update Date: 10/07/2022
Certification Date: 10/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 SOUTHGATE STE 13
PENDLETON OR
97801-3973
US

IV. Provider business mailing address

1100 SOUTHGATE STE 13
PENDLETON OR
97801-3973
US

V. Phone/Fax

Practice location:
  • Phone: 541-278-2222
  • Fax: 541-276-8405
Mailing address:
  • Phone: 541-278-2222
  • Fax: 541-276-8405

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number3109
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: