Healthcare Provider Details

I. General information

NPI: 1245163179
Provider Name (Legal Business Name): AVALON WELLNESS LIVING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/08/2026
Last Update Date: 06/08/2026
Certification Date: 06/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19495 SW BLANTON ST
BEAVERTON OR
97078-1220
US

IV. Provider business mailing address

13205 SW WATKINS AVE
PORTLAND OR
97223-3870
US

V. Phone/Fax

Practice location:
  • Phone: 971-371-4474
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3104A0625X
TaxonomyAssisted Living Facility (Mental Illness)
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code323P00000X
TaxonomyPsychiatric Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: RAHEL MASRESHA
Title or Position: ADMINISTRATIVE DIRECTOR
Credential:
Phone: 503-740-4522