Healthcare Provider Details

I. General information

NPI: 1083605869
Provider Name (Legal Business Name): ELIZABETH QUACKENBUSH PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 11/02/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2493 STATE ST
SALEM OR
97301-4543
US

IV. Provider business mailing address

2493 STATE ST
SALEM OR
97301-4543
US

V. Phone/Fax

Practice location:
  • Phone: 503-588-1010
  • Fax: 503-588-9424
Mailing address:
  • Phone: 503-588-1010
  • Fax: 503-588-9424

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number1096
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: