| Southern Oregon Neuropsychological Clinic Llc | |
|
837 Alder Creek Dr Medford OR 97504 | |
| (541) 608-3878 | |
| (541) 608-3880 |
| Full Name | Southern Oregon Neuropsychological Clinic Llc |
|---|---|
| Speciality | Clinical Neuropsychologist |
| Location | 837 Alder Creek Dr, Medford, Oregon |
| Authorized Official Name and Position | Michael R Villanueva (OWNER) |
| Authorized Official Contact | 5416083878 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Southern Oregon Neuropsychological Clinic Llc 837 Alder Creek Dr Medford OR 97504-8911 Ph: (541) 608-3878 | Southern Oregon Neuropsychological Clinic Llc 837 Alder Creek Dr Medford OR 97504 Ph: (541) 608-3878 |
| NPI Number | 1588726939 |
|---|---|
| Provider Enumeration Date | 12/14/2006 |
| Last Update Date | 07/16/2018 |
| Medicare PECOS PAC ID | 8729050877 |
|---|---|
| Medicare Enrollment ID | O20040809001385 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1588726939 | NPI | - | NPPES |
| 042601 | Medicaid | OR |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 103G00000X | Clinical Neuropsychologist | (* (Not Available)) | Primary |
| 103TC0700X | Psychologist - Clinical | (* (Not Available)) | Secondary |
| Provider Name | Michael R Villanueva |
|---|---|
| Provider Type | Practitioner - Clinical Psychologist |
| Provider Identifiers | NPI Number: 1063522860 PECOS PAC ID: 0042341711 Enrollment ID: I20130514000768 |
| Provider Name | Jonathan Sterling Beck |
|---|---|
| Provider Type | Practitioner - Clinical Psychologist |
| Provider Identifiers | NPI Number: 1093293680 PECOS PAC ID: 8325444185 Enrollment ID: I20210902002832 |
| Provider Name | Kristin Elizabeth Maple |
|---|---|
| Provider Type | Practitioner - Clinical Psychologist |
| Provider Identifiers | NPI Number: 1174290415 PECOS PAC ID: 6305242934 Enrollment ID: I20210908000943 |
| Provider Name | Katie Morgan Hannah-fisher |
|---|---|
| Provider Type | Practitioner - Clinical Psychologist |
| Provider Identifiers | NPI Number: 1164871919 PECOS PAC ID: 9032514955 Enrollment ID: I20211001003009 |
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