Healthcare Provider Details

I. General information

NPI: 1366036840
Provider Name (Legal Business Name): ROSE CITY THERAPISTS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/24/2021
Last Update Date: 07/30/2024
Certification Date: 03/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3434 S KELLY AVE
PORTLAND OR
97239-4630
US

IV. Provider business mailing address

3747 SE MORRISON ST
PORTLAND OR
97214-3209
US

V. Phone/Fax

Practice location:
  • Phone: 503-908-3012
  • Fax: 503-908-2382
Mailing address:
  • Phone: 503-908-3012
  • Fax: 503-908-2382

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: PATRICK GLUZINSKI
Title or Position: PRACTICE MANAGER
Credential:
Phone: 503-908-3012