=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306352281
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PHOENIX RISING PSYCHOLOGY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/14/2017
-----------------------------------------------------
Last Update Date | 12/14/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1515 NW 23RD AVE
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97210-2617
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-123-8965
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3522 NE 61ST AVE
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97213-3210
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 971-238-9656
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LICENSED PSYCHOLOGIST
-----------------------------------------------------
Name | DR. SARAH ANNE VORUZ
-----------------------------------------------------
Credential | PSY.D.
-----------------------------------------------------
Telephone | 971-238-9656
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0850X
-----------------------------------------------------
Taxonomy Name | Adult Mental Health Clinic/Center
-----------------------------------------------------
License Number | 2610
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------