MEDICARE: DEEP INSIGHT GROUP PLLC

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	363LP0808X	Psychiatric/Mental Health Nurse Practitioner

General Provider Information

NPI Number	:	1366141517
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DEEP INSIGHT GROUP PLLC

Provider Business Mailing Address
First Line	:	6400 SE LAKE RD STE 430
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97222-2129
Country	:	US
Telephone Number	:	971-358-9292
Fax Number	:	503-917-4971

Provider Business Practice Location Address
First Line	:	1925 VILLAGE CENTER CIR STE 150
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89134-6261
Country	:	US
Telephone Number	:	725-212-4523
Fax Number	:	725-212-4524

Authorized Official
Title or Position	:	MEDICAL DIRECTOR
Name	:	MISS SHAWN DEREMER DAWN MOORE
Credential	:	MD
Telephone Number	:	971-358-9292

Provider Enumeration Date	:	02/27/2023
Last Update Date	:	02/27/2023

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