Provider Demographics
NPI:1073279741
Name:REITEN, SOPHIA GRACE
Entity Type:Individual
Prefix:
First Name:SOPHIA
Middle Name:GRACE
Last Name:REITEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:668 MCVEY AVE UNIT 80
Mailing Address - Street 2:
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97034-4811
Mailing Address - Country:US
Mailing Address - Phone:208-515-6575
Mailing Address - Fax:
Practice Address - Street 1:1675 SW MARLOW AVE STE 200
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-5102
Practice Address - Country:US
Practice Address - Phone:866-523-4268
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-16
Last Update Date:2021-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician