NPIMap

Organization Active NPI

Geromedical Psychological Service PS

  • Clinical Psychologist
  • Portland, OR
National Provider Identifier
1043501836
Registry record updated Sep 17, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Clinical PsychologistTaxonomy code 103TC0700X
License
2074 Issued in OR
Legal business name
GEROMEDICAL PSYCHOLOGICAL SERVICE PS
Practice address
3550 SW Bond Ave
Portland, OR 97239-4507
Phone
(360) 574-9565
Fax
(360) 574-9685
NPI assigned
Apr 27, 2011
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Sep 17, 2020

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Dr. Derick A Scovel, PHD
Title
President
Phone
(360) 574-9565

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Clinical PsychologistGroup: 193400000X SINGLE SPECIALTY GROUP 103TC0700X 2074 OR Primary

Addresses

Primary practice location

3550 SW Bond Ave
Portland, OR 97239-4507

Mailing address

2400 Main St
Vancouver, WA 98660-2663
Phone (360) 574-9565

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in OR

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20110623000712 OR Part B Supplier - Clinic/Group Practice 9436180684 Receives reassigned benefits from 1 practitioner
Practice locations: Portland, OR

Other NPIs with the same Medicare PAC ID 1

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

National Provider Directory

National Provider Directory
Tax ID family
Geromedical Psychological Service PS2 organizations share this tax ID, including this one

Other organizations with this tax ID 1

Organizations that report the same tax identification number in the National Provider Directory.

Locations

23 SE 103rd Ave
Portland, OR 97216
Phone (503) 254-5900

510 N Parkway Ave
Battle Ground, WA 98604
Phone (360) 687-5141

10000 NE 7th Ave
Ste 215
Vancouver, WA 98685
Phone (360) 574-9595

208 E 25th St
Vancouver, WA 98663
Phone 3609101522 ext. 3001

17171 SE 22nd Dr
Vancouver, WA 98683
Phone (360) 859-0286

Practitioners & affiliated clinicians

Practitioners 10

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1303862400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1600300800000",
    "number": "1043501836",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2400 MAIN ST",
            "city": "VANCOUVER",
            "state": "WA",
            "postal_code": "986602663",
            "telephone_number": "360-574-9565",
            "fax_number": "360-574-9685"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3550 SW BOND AVE",
            "city": "PORTLAND",
            "state": "OR",
            "postal_code": "972394507",
            "telephone_number": "360-574-9565",
            "fax_number": "360-574-9685"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "GEROMEDICAL PSYCHOLOGICAL SERVICE PS",
        "organizational_subpart": "NO",
        "enumeration_date": "2011-04-27",
        "last_updated": "2020-09-17",
        "certification_date": "2020-09-17",
        "status": "A",
        "authorized_official_last_name": "SCOVEL",
        "authorized_official_first_name": "DERICK",
        "authorized_official_middle_name": "A",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "360-574-9565",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "PHD"
    },
    "taxonomies": [
        {
            "code": "103TC0700X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Psychologist, Clinical",
            "state": "OR",
            "license": "2074",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Portland, OR

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 17, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.