MEDICARE: VICTORIA FELLINGHAM MSW

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	A2009	OR

General Provider Information

NPI Number	:	1639212632
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	VICTORIA FELLINGHAM MSW

Provider Business Mailing Address
First Line	:	5720 SW CORBETT AVE
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97239-3706
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1500 NE IRVING ST
Second Line	:	SUITE 250
City	:	PORTLAND
State	:	OR
Zip	:	97232-2243
Country	:	US
Telephone Number	:	503-233-4356
Fax Number	:

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

Provider Enumeration Date	:	02/15/2007
Last Update Date	:	07/08/2007

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