MEDICARE: LOREN E MALLORY PHD, ABPP

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	103TC0700X	Clinical Psychologist	0978	OR
2	103G00000X	Clinical Neuropsychologist	978	OR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	117227	OTHER		MHN HMC
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1992853402
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LOREN E MALLORY PHD, ABPP

Provider Business Mailing Address
First Line	:	619 MADISON ST STE 108
Second Line	:
City	:	OREGON CITY
State	:	OR
Zip	:	97045-2354
Country	:	US
Telephone Number	:	503-303-4257
Fax Number	:	503-387-3957

Provider Business Practice Location Address
First Line	:	619 MADISON ST STE 108
Second Line	:
City	:	OREGON CITY
State	:	OR
Zip	:	97045-2354
Country	:	US
Telephone Number	:	503-303-4257
Fax Number	:	503-387-3957

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

Provider Enumeration Date	:	01/08/2007
Last Update Date	:	04/09/2018

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