Healthcare Provider Details

I. General information

NPI: 1689884751
Provider Name (Legal Business Name): PORTLAND HEALTH AND WELLNESS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/23/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1821 SE ANKENY ST
PORTLAND OR
97214-1521
US

IV. Provider business mailing address

1821 SE ANKENY ST
PORTLAND OR
97214-1521
US

V. Phone/Fax

Practice location:
  • Phone: 503-236-4506
  • Fax: 503-236-4501
Mailing address:
  • Phone: 503-236-4506
  • Fax: 503-236-4501

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TP0016X
TaxonomyPrescribing (Medical) Psychologist
License Number1224715-1
License Number StateOR

VIII. Authorized Official

Name: MS. JOYCE E STILWELL
Title or Position: OFFICE MANAGER
Credential:
Phone: 503-236-4506