Basic Information
Provider Information | |||||||||
NPI: | 1316354970 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | UNIVERSITY PROFESSIONAL SERVICES | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | OHSU AVEL GORDLY CENTER FOR HEALING | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2055 NW SAVIER ST. | ||||||||
Address2: | SUITE 201 | ||||||||
City: | PORTLAND | ||||||||
State: | OR | ||||||||
PostalCode: | 972091773 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5034948417 | ||||||||
FaxNumber: | 5033468021 | ||||||||
Practice Location | |||||||||
Address1: | 621 SW ALDER ST | ||||||||
Address2: | SUITE 520 | ||||||||
City: | PORTLAND | ||||||||
State: | OR | ||||||||
PostalCode: | 972053626 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5034944745 | ||||||||
FaxNumber: | 5034944747 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/16/2014 | ||||||||
LastUpdateDate: | 07/16/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HECKLER | ||||||||
AuthorizedOfficialFirstName: | THOMAS | ||||||||
AuthorizedOfficialMiddleName: | M. | ||||||||
AuthorizedOfficialTitleorPosition: | SENIOR ASSOCIATE DEAN | ||||||||
AuthorizedOfficialTelephone: | 5034944481 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | UNIVERSITY PROFESSIONAL SERVICES | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0405X |   |   | N |   | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder | 261QM0801X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
No ID Information.