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General NPI Number Information
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NPI Number | 1902927478
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Entity Type | Organization
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Legal Business Name | NORTHWEST CHILD AND FAMILY CLINIC, P.C.
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Dates
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Enumeration Date | 04/03/2007
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Last Update Date | 03/07/2008
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Provider Practice Location Address
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Address Line | 14619 NE 82ND AVE
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City | VANCOUVER
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State | WA
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Zip | 98662-1057
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Country | US
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Telephone | 503-636-4333
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Fax |
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Provider Business Mailing Address
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Address Line | 14619 NE 82ND AVE
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City | VANCOUVER
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State | WA
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Zip | 98662-1057
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Country | US
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Telephone | 503-636-4333
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. SHARON BAST GAVORA
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Credential | PSY.D.
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Telephone | 503-636-4333
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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 | 1373
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License Number State | OR
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Taxonomy #2
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | TE00003919
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License Number State | WA
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