Healthcare Provider Details

I. General information

NPI: 1295899425
Provider Name (Legal Business Name): LARRY L HALTER PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/21/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7455 SW BEVELAND RD
TIGARD OR
97223-8610
US

IV. Provider business mailing address

PO BOX 82819
PORTLAND OR
97282-0819
US

V. Phone/Fax

Practice location:
  • Phone: 503-624-2600
  • Fax: 503-624-7752
Mailing address:
  • Phone: 503-233-5405
  • Fax: 503-233-2696

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number1037
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: