Basic Information
| Provider Information | |||||||||
| NPI: | 1669088050 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TRAUMA HEALING NW, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4800 MEADOWS RD STE 300 | ||||||||
| Address2: | |||||||||
| City: | LAKE OSWEGO | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970355277 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9712011720 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4800 MEADOWS RD STE 300 | ||||||||
| Address2: | |||||||||
| City: | LAKE OSWEGO | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970355277 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9712011720 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2020 | ||||||||
| LastUpdateDate: | 09/21/2020 | ||||||||
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| AuthorizedOfficialLastName: | NELSON | ||||||||
| AuthorizedOfficialFirstName: | LYNAE | ||||||||
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| AuthorizedOfficialTitleorPosition: | MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 9712011720 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | LPC | ||||||||
| NPICertificationDate: | 09/21/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | C4674 | 01 | OR | OBLPCT | OTHER |