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General NPI Number Information
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NPI Number | 1659482925
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Entity Type | Organization
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Legal Business Name | GEROMEDICAL PSYCHOLOGICAL SERVICE PS
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Dates
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Enumeration Date | 08/31/2006
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Last Update Date | 09/17/2020
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Provider Practice Location Address
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Address Line | 2400 MAIN ST
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City | VANCOUVER
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State | WA
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Zip | 98660-2663
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Country | US
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Telephone | 360-574-9565
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Fax | 360-574-9685
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Provider Business Mailing Address
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Address Line | 2400 MAIN ST
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City | VANCOUVER
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State | WA
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Zip | 98660-2663
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Country | US
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Telephone | 360-574-9565
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Fax | 360-574-9685
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Authorized Official
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Title or Position | V. PRESIDENT
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Name | DR. DERICK A SCOVEL
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Credential | PHD
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Telephone | 360-574-9565
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | PY2484
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License Number State | WA
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