Provider Demographics
NPI:1902208846
Name:360 PEDIATRIC PSYCHOLOGY, PC
Entity Type:Organization
Organization Name:360 PEDIATRIC PSYCHOLOGY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL PSYCHOLOGIST COOWNER/PARTN
Authorized Official - Prefix:DR
Authorized Official - First Name:TABITHA
Authorized Official - Middle Name:SEREUA
Authorized Official - Last Name:BECKER
Authorized Official - Suffix:
Authorized Official - Credentials:PSY D
Authorized Official - Phone:503-720-9234
Mailing Address - Street 1:201 B AVE.
Mailing Address - Street 2:SUITE #285
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97034
Mailing Address - Country:US
Mailing Address - Phone:503-636-0508
Mailing Address - Fax:503-636-0387
Practice Address - Street 1:201 B AVE.
Practice Address - Street 2:SUITE #285
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97034
Practice Address - Country:US
Practice Address - Phone:503-636-0508
Practice Address - Fax:503-636-0387
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-23
Last Update Date:2014-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Multi-Specialty
No103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Multi-Specialty