Healthcare Provider Details

I. General information

NPI: 1134058001
Provider Name (Legal Business Name): OLDTOWN COUNSELING AND CONSULTATION, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2026
Last Update Date: 05/18/2026
Certification Date: 05/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4295 SW TEGART LN
GRESHAM OR
97080-8653
US

IV. Provider business mailing address

4295 SW TEGART LN
GRESHAM OR
97080-8653
US

V. Phone/Fax

Practice location:
  • Phone: 971-425-6524
  • Fax:
Mailing address:
  • Phone: 971-425-6524
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: MR. RYAN ALTSTADT
Title or Position: COUNSELOR; MEMBER
Credential: LPC
Phone: 971-425-6524