Healthcare Provider Details

I. General information

NPI: 1245378546
Provider Name (Legal Business Name): FORA HEALTH INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/01/2007
Last Update Date: 07/27/2022
Certification Date: 07/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10230 SE CHERRY BLOSSOM DR
PORTLAND OR
97216
US

IV. Provider business mailing address

P.O.BOX 16040
PORTLAND OR
97292
US

V. Phone/Fax

Practice location:
  • Phone: 503-535-1150
  • Fax: 503-535-1190
Mailing address:
  • Phone: 503-535-1150
  • Fax: 503-535-1190

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number StateOR
# 3
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number StateOR
# 4
Primary TaxonomyN
Taxonomy Code3245S0500X
TaxonomyChildren's Substance Abuse Rehabilitation Facility
License Number
License Number StateOR
# 5
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateOR
# 6
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateOR
# 7
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number StateOR
# 8
Primary TaxonomyN
Taxonomy Code261QR0401X
TaxonomyComprehensive Outpatient Rehabilitation Facility (CORF)
License Number
License Number StateOR
# 9
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number StateOR

VIII. Authorized Official

Name: MALLORY JUANITA-ANN JOHNSON
Title or Position: CONTRACT COORDINATOR
Credential:
Phone: 503-535-1156