Provider Demographics
NPI:1073146197
Name:REBEL HEART THERAPY LLC
Entity Type:Organization
Organization Name:REBEL HEART THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FOUNDER
Authorized Official - Prefix:MS
Authorized Official - First Name:MORGAN
Authorized Official - Middle Name:
Authorized Official - Last Name:FITZ GIBBON
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:971-350-1122
Mailing Address - Street 1:11 NE MLK BLVD STE 203
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97232-3579
Mailing Address - Country:US
Mailing Address - Phone:971-350-1122
Mailing Address - Fax:971-350-3401
Practice Address - Street 1:11 NE MLK BLVD STE 203
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232-3579
Practice Address - Country:US
Practice Address - Phone:971-350-1122
Practice Address - Fax:971-350-3401
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-17
Last Update Date:2022-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)Group - Single Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty