Healthcare Provider Details

I. General information

NPI: 1720946569
Provider Name (Legal Business Name): UNDERDOG ALCHEMY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/12/2026
Last Update Date: 01/12/2026
Certification Date: 01/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22400 SE STARK ST
GRESHAM OR
97030-2600
US

IV. Provider business mailing address

22400 SE STARK ST STE 104
GRESHAM OR
97030-2618
US

V. Phone/Fax

Practice location:
  • Phone: 971-486-6182
  • Fax: 971-293-4016
Mailing address:
  • Phone: 971-486-6182
  • Fax: 971-293-4016

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MISHA HARDISON LOVE
Title or Position: PSYCHIATRIC NURSE PRACTITIONER
Credential: RN MSN, PMHNP-BC
Phone: 971-486-6182