=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861253288
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | UNRAVEL AWARENESS PSYCHOTHERAPY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/22/2024
-----------------------------------------------------
Last Update Date | 01/22/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9025 NE SACRAMENTO ST
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97220-5458
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 971-373-7728
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9025 NE SACRAMENTO ST
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97220-5458
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 971-373-7728
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LICENSED CLINICAL SOCIAL WORKER
-----------------------------------------------------
Name | RHEN MILES
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 971-373-7728
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0850X
-----------------------------------------------------
Taxonomy Name | Adult Mental Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------