Healthcare Provider Details

I. General information

NPI: 1871658997
Provider Name (Legal Business Name): NORTHSIDE FAMILY COUNSELING, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/27/2006
Last Update Date: 11/09/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

51579 COLUMBIA RIVER HWY STE 'I'
SCAPPOOSE OR
97056-8411
US

IV. Provider business mailing address

51579 COLUMBIA RIVER HWY STE 'I'
SCAPPOOSE OR
97056-8411
US

V. Phone/Fax

Practice location:
  • Phone: 503-543-6164
  • Fax: 503-543-6040
Mailing address:
  • Phone: 503-543-6164
  • Fax: 503-543-6040

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberL2799
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberT0349
License Number StateOR
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberL1330
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: CHARLES E RAHE
Title or Position: DIRECTOR
Credential: LCSW
Phone: 503-543-6164