Healthcare Provider Details

I. General information

NPI: 1104533983
Provider Name (Legal Business Name): NOREEN RENAE SABLAN DELA ROSA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/01/2022
Last Update Date: 09/11/2026
Certification Date: 09/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4101 NE DIVISION ST
GRESHAM OR
97030-4617
US

IV. Provider business mailing address

4101 NE DIVISION ST
GRESHAM OR
97030-4617
US

V. Phone/Fax

Practice location:
  • Phone: 503-666-6575
  • Fax:
Mailing address:
  • Phone: 503-666-6575
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCG61668972
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: