Healthcare Provider Details

I. General information

NPI: 1699667642
Provider Name (Legal Business Name): LAMB OF GOD CLOTHING AND ACCESSORIES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/16/2025
Last Update Date: 07/22/2025
Certification Date: 07/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

259 NW MILLER AVE
GRESHAM OR
97030-7260
US

IV. Provider business mailing address

259 NW MILLER AVE
GRESHAM OR
97030-7260
US

V. Phone/Fax

Practice location:
  • Phone: 503-451-3385
  • Fax:
Mailing address:
  • Phone: 503-451-3385
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: AMBROSIA JOHNSON
Title or Position: FOUNDER & DIRECTOR
Credential: THW, PSS
Phone: 503-451-3385