MEDICARE: CONNECT THRIVE THERAPY, LLC

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	261QM0850X	Adult Mental Health Clinic/Center
2	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1851042279
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CONNECT THRIVE THERAPY, LLC

Provider Business Mailing Address
First Line	:	PO BOX 2044
Second Line	:
City	:	LAKE OSWEGO
State	:	OR
Zip	:	97035-0631
Country	:	US
Telephone Number	:	971-339-1662
Fax Number	:

Provider Business Practice Location Address
First Line	:	4800 MEADOWS RD STE 320
Second Line	:
City	:	LAKE OSWEGO
State	:	OR
Zip	:	97035-4264
Country	:	US
Telephone Number	:	971-339-1662
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	NICOLE PHELPS
Credential	:	LCSW
Telephone Number	:	971-339-1662

Provider Enumeration Date	:	01/18/2022
Last Update Date	:	01/18/2022

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