Provider Demographics
NPI:1508992652
Name:PORTLAND PEDIATRIC PSYCHOLOGY, LLC
Entity Type:Organization
Organization Name:PORTLAND PEDIATRIC PSYCHOLOGY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/THERAPIST
Authorized Official - Prefix:DR
Authorized Official - First Name:GLORI
Authorized Official - Middle Name:GRUBBS
Authorized Official - Last Name:GRAY
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD, MSW
Authorized Official - Phone:503-673-6246
Mailing Address - Street 1:1012 SW KING AVE.
Mailing Address - Street 2:SUITE 105
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97205-3035
Mailing Address - Country:US
Mailing Address - Phone:503-673-6246
Mailing Address - Fax:
Practice Address - Street 1:1012 SW KING AVE.
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97205-1106
Practice Address - Country:US
Practice Address - Phone:503-673-6246
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-25
Last Update Date:2015-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2482251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3598OtherCAROLINAS BEHAVIORAL HEAL
NC135J9OtherBLUE CROSS BLUE SHIELD
NC6002627Medicaid