Healthcare Provider Details

I. General information

NPI: 1760129829
Provider Name (Legal Business Name): RADIANT MIND
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2022
Last Update Date: 05/18/2022
Certification Date: 05/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8638A N LOMBARD ST STE 3
PORTLAND OR
97203-3741
US

IV. Provider business mailing address

9707 N CLARENDON AVE
PORTLAND OR
97203-1917
US

V. Phone/Fax

Practice location:
  • Phone: 503-386-1972
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ANNAMARIE HARRISON
Title or Position: ADMINISTRATIVE ASSISTANT
Credential:
Phone: 503-386-1972