Provider Demographics
NPI:1578637096
Name:SPEECH PATHOLOGY ASSOCIATES
Entity Type:Organization
Organization Name:SPEECH PATHOLOGY ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BLAISE
Authorized Official - Middle Name:
Authorized Official - Last Name:SCOLLARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-665-1151
Mailing Address - Street 1:PO BOX 82608
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97282-0608
Mailing Address - Country:US
Mailing Address - Phone:503-665-1151
Mailing Address - Fax:503-669-1986
Practice Address - Street 1:5905 SE POWELL VALLEY RD
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97080-1919
Practice Address - Country:US
Practice Address - Phone:503-665-1151
Practice Address - Fax:503-669-1986
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-17
Last Update Date:2008-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR10394235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR286005Medicaid