Provider Demographics
NPI:1992853402
Name:MALLORY, LOREN E (PHD, ABPP)
Entity type:Individual
Prefix:
First Name:LOREN
Middle Name:E
Last Name:MALLORY
Suffix:
Gender:M
Credentials:PHD, ABPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:619 MADISON ST STE 108
Mailing Address - Street 2:
Mailing Address - City:OREGON CITY
Mailing Address - State:OR
Mailing Address - Zip Code:97045-2354
Mailing Address - Country:US
Mailing Address - Phone:503-303-4257
Mailing Address - Fax:503-387-3957
Practice Address - Street 1:619 MADISON ST STE 108
Practice Address - Street 2:
Practice Address - City:OREGON CITY
Practice Address - State:OR
Practice Address - Zip Code:97045-2354
Practice Address - Country:US
Practice Address - Phone:503-303-4257
Practice Address - Fax:503-387-3957
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2018-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR0978103TC0700X
OR978103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
117227OtherMHN HMC
OR042544Medicaid
00WFBFMFMedicare ID - Type Unspecified
R14344Medicare UPIN