Provider Demographics
NPI:1548460637
Name:PEDERSON, CONSTANCE ELDRIDGE (PHD)
Entity type:Individual
Prefix:DR
First Name:CONSTANCE
Middle Name:ELDRIDGE
Last Name:PEDERSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10117 SE SUNNYSIDE RD # F1217
Mailing Address - Street 2:
Mailing Address - City:CLACKAMAS
Mailing Address - State:OR
Mailing Address - Zip Code:97015-7708
Mailing Address - Country:US
Mailing Address - Phone:503-740-1971
Mailing Address - Fax:503-284-6051
Practice Address - Street 1:3939 NE HANCOCK ST STE 301
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97212-5321
Practice Address - Country:US
Practice Address - Phone:503-287-4426
Practice Address - Fax:503-284-6051
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-18
Last Update Date:2021-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1070103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR12322686OtherCAQH