Healthcare Provider Details

I. General information

NPI: 1548460637
Provider Name (Legal Business Name): CONSTANCE ELDRIDGE PEDERSON PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2007
Last Update Date: 08/12/2025
Certification Date: 08/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3939 NE HANCOCK ST STE 301
PORTLAND OR
97212-5321
US

IV. Provider business mailing address

10117 SE SUNNYSIDE RD # F1217
CLACKAMAS OR
97015-7708
US

V. Phone/Fax

Practice location:
  • Phone: 503-287-4426
  • Fax: 503-284-6051
Mailing address:
  • Phone: 503-740-1971
  • Fax: 503-284-6051

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License NumberT-24-4310
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number1070
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: