Provider Demographics
NPI:1679566848
Name:WILLIS, SCOTT CABOT (PHD)
Entity Type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:CABOT
Last Name:WILLIS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7157 SW BEVELAND RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97223-9628
Mailing Address - Country:US
Mailing Address - Phone:503-547-9505
Mailing Address - Fax:
Practice Address - Street 1:7157 SW BEVELAND RD
Practice Address - Street 2:SUITE 100
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97223-9628
Practice Address - Country:US
Practice Address - Phone:503-547-9505
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-23
Last Update Date:2013-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR919103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR042494Medicaid
ORR01326Medicare UPIN
OOOOTCHWPMedicare ID - Type Unspecified