Healthcare Provider Details

I. General information

NPI: 1740844539
Provider Name (Legal Business Name): NEW AVENUES FOR YOUTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/26/2019
Last Update Date: 01/13/2020
Certification Date: 01/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2595 CHRISTIE DR.
LAKE OSWEGO OR
97034
US

IV. Provider business mailing address

1220 SW COLUMBIA STREET
PORTLAND OR
97201
US

V. Phone/Fax

Practice location:
  • Phone: 503-517-3973
  • Fax: 503-517-3199
Mailing address:
  • Phone: 503-224-4339
  • Fax: 503-501-3198

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. SEAN SUIB
Title or Position: EXECUTIVE DIRECTOR
Credential: LCSW
Phone: 503-517-3921