Healthcare Provider Details

I. General information

NPI: 1376925339
Provider Name (Legal Business Name): HEAL THRIVE GROW BEHAVIORAL HEALTH, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/25/2015
Last Update Date: 12/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5200 SW MACADAM AVE STE 155
PORTLAND OR
97239-3833
US

IV. Provider business mailing address

5200 SW MACADAM AVE STE 580
PORTLAND OR
97239-3837
US

V. Phone/Fax

Practice location:
  • Phone: 503-290-3261
  • Fax: 503-231-8153
Mailing address:
  • Phone: 503-290-3261
  • Fax: 503-231-8153

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103TP2701X
TaxonomyGroup Psychotherapy Psychologist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number
License Number State

VIII. Authorized Official

Name: LOREN WAMPLER
Title or Position: BUSINESS OPERATIONS
Credential:
Phone: 503-290-3290