Provider Demographics
NPI:1144780552
Name:ALLEN, ERIC LEE
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:LEE
Last Name:ALLEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:912 NE KELLY AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97030-5631
Mailing Address - Country:US
Mailing Address - Phone:503-912-5502
Mailing Address - Fax:
Practice Address - Street 1:912 NE KELLY AVE
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-5629
Practice Address - Country:US
Practice Address - Phone:503-912-5502
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-21
Last Update Date:2019-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst