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General NPI Number Information
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NPI Number | 1902208846
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Entity Type | Organization
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Legal Business Name | 360 PEDIATRIC PSYCHOLOGY, PC
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Dates
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Enumeration Date | 09/23/2014
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Last Update Date | 09/23/2014
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Provider Practice Location Address
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Address Line | 201 B AVE. SUITE #285
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City | LAKE OSWEGO
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State | OR
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Zip | 97034
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Country | US
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Telephone | 503-636-0508
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Fax | 503-636-0387
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Provider Business Mailing Address
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Address Line | 201 B AVE. SUITE #285
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City | LAKE OSWEGO
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State | OR
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Zip | 97034
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Country | US
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Telephone | 503-636-0508
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Fax | 503-636-0387
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Authorized Official
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Title or Position | CLINICAL PSYCHOLOGIST COOWNER/PARTN
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Name | DR. TABITHA SEREUA BECKER
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Credential | PSY. D
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Telephone | 503-720-9234
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103G00000X
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Taxonomy Name | Clinical Neuropsychologist
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 103TC2200X
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Taxonomy Name | Clinical Child & Adolescent Psychologist
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License Number |
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License Number State |
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