Provider Demographics
NPI:1093165623
Name:GREEN HILLS PEDIATRIC THERAPY, INC.
Entity Type:Organization
Organization Name:GREEN HILLS PEDIATRIC THERAPY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPEECH-LANGUAGE PATHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ANNA
Authorized Official - Middle Name:JEDDELOH
Authorized Official - Last Name:WATERS
Authorized Official - Suffix:
Authorized Official - Credentials:EDD
Authorized Official - Phone:503-297-4052
Mailing Address - Street 1:5319 SW WESTGATE DR STE 120
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97221-2313
Mailing Address - Country:US
Mailing Address - Phone:503-297-4052
Mailing Address - Fax:503-297-4401
Practice Address - Street 1:5319 SW WESTGATE DR STE 120
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97221-2313
Practice Address - Country:US
Practice Address - Phone:503-297-4052
Practice Address - Fax:503-297-4401
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-14
Last Update Date:2016-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR13313261QH0700X
OR13433261QH0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0700XAmbulatory Health Care FacilitiesClinic/CenterHearing and Speech
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500693103Medicaid