=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821131558
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SELENA GRIFFIN LPC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/14/2007
-----------------------------------------------------
Last Update Date | 04/15/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 14600 NW CORNELL RD
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97229-5442
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-645-3581
-----------------------------------------------------
Fax | 503-629-8517
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15427 SW KENTON DR
-----------------------------------------------------
City | TIGARD
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97224-7377
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-789-6680
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | C2616
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------