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NPI Code Detail

MEDICARE: COLLIN WHITE-PEDEAUX

MEDICARE: COLLIN WHITE-PEDEAUX
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
1101YM0800XMental Health Counselor
21041C0700XClinical Social Worker

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1508206996
Entity Type Code : Individual
Provider Name (Legal Business Name) : COLLIN WHITE-PEDEAUX
Provider Business Mailing Address
First Line : 4101 NE DIVISION ST
Second Line : 100
City : GRESHAM
State : OR
Zip : 97030-4617
Country : US
Telephone Number : 503-666-3808
Fax Number : 503-666-6835
Provider Business Practice Location Address
First Line : 1825 NE GLISAN ST
Second Line :
City : PORTLAND
State : OR
Zip : 97232-2844
Country : US
Telephone Number : 503-963-7676
Fax Number : 503-764-9042
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/28/2013
Last Update Date : 01/22/2020

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Directions to “ COLLIN WHITE-PEDEAUX ” Practice Location

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