Healthcare Provider Details

I. General information

NPI: 1306229596
Provider Name (Legal Business Name): PLAY2GROW BEHAVIORAL THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2015
Last Update Date: 07/07/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8050 SW WARM SPRINGS ST STE 130
TUALATIN OR
97062-7401
US

IV. Provider business mailing address

8050 SW WARM SPRINGS ST STE 130
TUALATIN OR
97062-7401
US

V. Phone/Fax

Practice location:
  • Phone: 503-564-0565
  • Fax:
Mailing address:
  • Phone: 503-564-0565
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number1948
License Number StateOR

VIII. Authorized Official

Name: CAROL MARKOVICS
Title or Position: CLINICAL PSYCHOLOGIST
Credential: PHD
Phone: 503-563-5280