Healthcare Provider Details

I. General information

NPI: 1073146197
Provider Name (Legal Business Name): REBEL HEART THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/17/2020
Last Update Date: 02/10/2022
Certification Date: 02/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 NE MLK BLVD STE 203
PORTLAND OR
97232-3579
US

IV. Provider business mailing address

11 NE MLK BLVD STE 203
PORTLAND OR
97232-3579
US

V. Phone/Fax

Practice location:
  • Phone: 971-350-1122
  • Fax: 971-350-3401
Mailing address:
  • Phone: 971-350-1122
  • Fax: 971-350-3401

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name: MS. MORGAN FITZ GIBBON
Title or Position: FOUNDER
Credential: LMFT
Phone: 971-350-1122