Provider Demographics
NPI: | 1821511403 |
---|---|
Name: | SALLY J GROSSCUP, PHD, PC |
Entity Type: | Organization |
Organization Name: | SALLY J GROSSCUP, PHD, PC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | OFFICE MANAGER |
Authorized Official - Prefix: | |
Authorized Official - First Name: | CASSIDY |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | HELMS |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 541-343-2663 |
Mailing Address - Street 1: | 1210 PEARL ST |
Mailing Address - Street 2: | |
Mailing Address - City: | EUGENE |
Mailing Address - State: | OR |
Mailing Address - Zip Code: | 97401-3573 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 541-343-2663 |
Mailing Address - Fax: | 541-343-2663 |
Practice Address - Street 1: | 1210 PEARL ST |
Practice Address - Street 2: | |
Practice Address - City: | EUGENE |
Practice Address - State: | OR |
Practice Address - Zip Code: | 97401-3573 |
Practice Address - Country: | US |
Practice Address - Phone: | 541-343-2663 |
Practice Address - Fax: | 541-343-2663 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2017-07-25 |
Last Update Date: | 2022-07-21 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
OR | 658 | 103T00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 103T00000X | Behavioral Health & Social Service Providers | Psychologist | Group - Single Specialty |