Healthcare Provider Details

I. General information

NPI: 1063342020
Provider Name (Legal Business Name): NEURONEST PSYCHIATRY ASSOCIATES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/21/2026
Last Update Date: 05/21/2026
Certification Date: 05/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 SE 225TH AVE
GRESHAM OR
97030-2669
US

IV. Provider business mailing address

20300 SE MORRISON TER APT 2037
GRESHAM OR
97030-2274
US

V. Phone/Fax

Practice location:
  • Phone: 972-876-9690
  • Fax:
Mailing address:
  • Phone: 972-876-9690
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: MR. SAMUEL MAINA
Title or Position: DIRECTOR
Credential:
Phone: 972-876-9690