Healthcare Provider Details

I. General information

NPI: 1730283813
Provider Name (Legal Business Name): ANDREW P ELLIS PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/11/2006
Last Update Date: 12/15/2021
Certification Date: 12/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1815 SW MARLOW SUITE 110
PORTLAND OR
97225-5185
US

IV. Provider business mailing address

7204 SW DURHAM RD STE 100
PORTLAND OR
97224-7574
US

V. Phone/Fax

Practice location:
  • Phone: 503-292-0765
  • Fax: 503-292-5208
Mailing address:
  • Phone: 503-941-9869
  • Fax: 503-352-5555

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number1396
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: