Provider Demographics
NPI:1447624663
Name:WESTERN PSYCHOLOGICAL AND COUNSELING SERVICES PC
Entity type:Organization
Organization Name:WESTERN PSYCHOLOGICAL AND COUNSELING SERVICES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONTRACT AND CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:ROBERTSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-233-5405
Mailing Address - Street 1:22070 NE CHINOOK WAY
Mailing Address - Street 2:
Mailing Address - City:FAIRVIEW
Mailing Address - State:OR
Mailing Address - Zip Code:97024-2647
Mailing Address - Country:US
Mailing Address - Phone:971-275-0294
Mailing Address - Fax:
Practice Address - Street 1:22070 NE CHINOOK WAY
Practice Address - Street 2:
Practice Address - City:FAIRVIEW
Practice Address - State:OR
Practice Address - Zip Code:97024-2647
Practice Address - Country:US
Practice Address - Phone:971-275-0294
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-26
Last Update Date:2018-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH 60489053302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0000WDBCH-WAMedicaid