MEDICARE: TABITHA BECKER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103G00000X	Clinical Neuropsychologist	2484	OR
2	103TC0700X	Clinical Psychologist	2484	OR
3	103TC2200X	Clinical Child & Adolescent Psychologist	2484	OR
4	103TH0004X	Health Psychologist	2484	OR
5	103TM1800X	Intellectual & Developmental Disabilities Psychologist	2484	OR

General Provider Information

NPI Number	:	1023411485
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TABITHA BECKER

Provider Business Mailing Address
First Line	:	201 B AVE
Second Line	:	SUITE 285
City	:	LAKE OSWEGO
State	:	OR
Zip	:	97034-3159
Country	:	US
Telephone Number	:	503-636-0508
Fax Number	:	503-636-0387

Provider Business Practice Location Address
First Line	:	201 B AVE
Second Line	:	SUITE 285
City	:	LAKE OSWEGO
State	:	OR
Zip	:	97034-3159
Country	:	US
Telephone Number	:	503-636-0508
Fax Number	:	503-636-0387

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/30/2014
Last Update Date	:	09/30/2014

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Directions to “ TABITHA BECKER ” Practice Location

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