Provider Demographics
NPI:1447281977
Name:TAN, ERICA SN (LCP)
Entity type:Individual
Prefix:MS
First Name:ERICA
Middle Name:SN
Last Name:TAN
Suffix:
Gender:F
Credentials:LCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5200 SW MACADAM AVE
Mailing Address - Street 2:SUITE 580
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-6103
Mailing Address - Country:US
Mailing Address - Phone:503-290-3266
Mailing Address - Fax:503-231-8153
Practice Address - Street 1:5200 SW MACADAM AVE
Practice Address - Street 2:SUITE 580
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-6103
Practice Address - Country:US
Practice Address - Phone:503-290-3266
Practice Address - Fax:503-231-8153
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2017-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2071103TC0700X
VA0810003589103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010232139Medicaid
VA009325E18Medicare ID - Type UnspecifiedCLINICAL PSYCHOLOGIST
VA010232139Medicaid