Healthcare Provider Details

I. General information

NPI: 1851054266
Provider Name (Legal Business Name): BEHAVIORAL NEUROPSYCHOLOGY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/21/2021
Last Update Date: 12/07/2022
Certification Date: 08/31/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2130 SW JEFFERSON ST STE 300
PORTLAND OR
97201-7711
US

IV. Provider business mailing address

2130 SW JEFFERSON ST STE 300
PORTLAND OR
97201-7711
US

V. Phone/Fax

Practice location:
  • Phone: 503-539-4932
  • Fax: 503-297-5744
Mailing address:
  • Phone: 503-539-4932
  • Fax: 503-297-5744

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TH0004X
TaxonomyHealth Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. MICHAEL J FULOP
Title or Position: OWNER
Credential: PSYD
Phone: 503-539-4932