Healthcare Provider Details

I. General information

NPI: 1649328089
Provider Name (Legal Business Name): CONSTANCE UMPHRED PH.D
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/08/2007
Last Update Date: 10/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 SE HAILEY AVE STE 204
PENDLETON OR
97801-3072
US

IV. Provider business mailing address

1101 I AVE
LA GRANDE OR
97850-2043
US

V. Phone/Fax

Practice location:
  • Phone: 541-962-0162
  • Fax: 541-663-4142
Mailing address:
  • Phone: 541-962-0162
  • Fax: 541-962-0119

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPY00001829
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: