Provider Demographics
NPI:1164042636
Name:CYNTHIA POLANCE PSYCHOLOGY
Entity Type:Organization
Organization Name:CYNTHIA POLANCE PSYCHOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:
Authorized Official - Last Name:POLANCE
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:503-869-4040
Mailing Address - Street 1:8125 SW RUBY TER
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97219-4649
Mailing Address - Country:US
Mailing Address - Phone:503-869-4040
Mailing Address - Fax:503-447-6640
Practice Address - Street 1:7912 SW 35TH AVE STE 3
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97219-2427
Practice Address - Country:US
Practice Address - Phone:503-278-4970
Practice Address - Fax:503-447-6640
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-24
Last Update Date:2020-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500770354Medicaid