Provider Demographics
NPI:1124808571
Name:LAWLESS, ELLIOTT (PSYD)
Entity type:Individual
Prefix:DR
First Name:ELLIOTT
Middle Name:
Last Name:LAWLESS
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12545 SW FAIRFIELD ST
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97005-1431
Mailing Address - Country:US
Mailing Address - Phone:626-201-2189
Mailing Address - Fax:
Practice Address - Street 1:414 N MERIDIAN ST
Practice Address - Street 2:
Practice Address - City:NEWBERG
Practice Address - State:OR
Practice Address - Zip Code:97132-2697
Practice Address - Country:US
Practice Address - Phone:503-554-2372
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-03
Last Update Date:2023-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2425103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty