MEDICARE: MR. DAVID EBAUGH LCSW

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	1041C0700X	Clinical Social Worker	L003678	OR

General Provider Information

NPI Number	:	1619015153
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. DAVID EBAUGH LCSW

Provider Business Mailing Address
First Line	:	6315 N CAMPBELL AVE
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97217-4914
Country	:	US
Telephone Number	:	503-345-3370
Fax Number	:

Provider Business Practice Location Address
First Line	:	2303 E BURNSIDE ST
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97214-1655
Country	:	US
Telephone Number	:	503-245-3370
Fax Number	:

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

Provider Enumeration Date	:	02/04/2007
Last Update Date	:	07/08/2007

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