Healthcare Provider Details

I. General information

NPI: 1649475641
Provider Name (Legal Business Name): NEW LEAVES CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/19/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 SW MARKET ST STE #390
PORTLAND OR
97201
US

IV. Provider business mailing address

5319 SW WESTGATE DR #241
PORTLAND OR
97221-2432
US

V. Phone/Fax

Practice location:
  • Phone: 503-274-0996
  • Fax:
Mailing address:
  • Phone: 503-297-7223
  • Fax: 503-297-7603

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number1594
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number1620
License Number StateOR

VIII. Authorized Official

Name: DR. CYNTHIA LYNNE ARNOLD
Title or Position: OWNER
Credential: PHD
Phone: 503-274-0996