Provider Demographics
NPI:1043501836
Name:GEROMEDICAL PSYCHOLOGICAL SERVICE PS
Entity Type:Organization
Organization Name:GEROMEDICAL PSYCHOLOGICAL SERVICE PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DERICK
Authorized Official - Middle Name:A
Authorized Official - Last Name:SCOVEL
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:360-574-9565
Mailing Address - Street 1:2400 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98660-2663
Mailing Address - Country:US
Mailing Address - Phone:360-574-9565
Mailing Address - Fax:360-574-9685
Practice Address - Street 1:3550 SW BOND AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-4507
Practice Address - Country:US
Practice Address - Phone:360-574-9565
Practice Address - Fax:360-574-9685
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-27
Last Update Date:2020-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2074103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR159409Medicare UPIN