=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124808571
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ELLIOTT LAWLESS PSY.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/03/2023
-----------------------------------------------------
Last Update Date | 10/03/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 414 N MERIDIAN ST
-----------------------------------------------------
City | NEWBERG
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97132-2697
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-554-2372
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12545 SW FAIRFIELD ST
-----------------------------------------------------
City | BEAVERTON
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97005-1431
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-201-2189
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 2425
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------