Provider Demographics
NPI:1487047007
Name:PSYCH NW, PC
Entity type:Organization
Organization Name:PSYCH NW, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:T
Authorized Official - Last Name:ALVORD
Authorized Official - Suffix:
Authorized Official - Credentials:PSY, D
Authorized Official - Phone:503-476-5005
Mailing Address - Street 1:PO BOX 10024
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97440-2024
Mailing Address - Country:US
Mailing Address - Phone:503-877-0711
Mailing Address - Fax:503-914-0315
Practice Address - Street 1:17704 JEAN WAY STE 105
Practice Address - Street 2:
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97035-5586
Practice Address - Country:US
Practice Address - Phone:503-877-0711
Practice Address - Fax:503-914-0315
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-05
Last Update Date:2015-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1929103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500614581MCDMedicaid