MEDICARE: GRACE THERESA NEVILLE RD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133V00000X	Registered Dietitian	86331131	OR

General Provider Information

NPI Number	:	1235094806
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GRACE THERESA NEVILLE RD

Provider Business Mailing Address
First Line	:	1630 SE RURAL ST APT 212
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97202-5861
Country	:	US
Telephone Number	:	503-477-0067
Fax Number	:

Provider Business Practice Location Address
First Line	:	1630 SE RURAL ST APT 212
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97202-5861
Country	:	US
Telephone Number	:	503-477-0067
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/17/2025
Last Update Date	:	12/17/2025

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Directions to “ GRACE THERESA NEVILLE RD” Practice Location

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