Healthcare Provider Details

I. General information

NPI: 1740018399
Provider Name (Legal Business Name): PACIFIC NORTHWEST TELETHERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/24/2024
Last Update Date: 04/08/2026
Certification Date: 04/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5441 S MACADAM AVE STE 8054
PORTLAND OR
97239-6106
US

IV. Provider business mailing address

5441 S MACADAM AVE STE 8054
PORTLAND OR
97239-6106
US

V. Phone/Fax

Practice location:
  • Phone: 503-383-9225
  • Fax:
Mailing address:
  • Phone: 503-383-9225
  • Fax: 458-234-4341

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: EMMA MOON
Title or Position: OWNER
Credential: LCSW
Phone: 503-383-9225