Healthcare Provider Details

I. General information

NPI: 1396340550
Provider Name (Legal Business Name): BEYOND THE SELF, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/03/2020
Last Update Date: 12/03/2020
Certification Date: 12/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5305 RIVER RD N STE B
KEIZER OR
97303-5324
US

IV. Provider business mailing address

304 NE MULTNOMAH ST APT 510
PORTLAND OR
97232-3615
US

V. Phone/Fax

Practice location:
  • Phone: 503-862-8238
  • Fax:
Mailing address:
  • Phone: 503-862-8238
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number
License Number State

VIII. Authorized Official

Name: ANETA BUJNO
Title or Position: OWNER
Credential: LCSW, RN
Phone: 503-862-8238