Provider Demographics
NPI:1083385140
Name:BLACK THERAPY PORTLAND
Entity Type:Organization
Organization Name:BLACK THERAPY PORTLAND
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER & MENTAL HEALTH THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:MISAO
Authorized Official - Middle Name:
Authorized Official - Last Name:ELIAHIM
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT ASSOCIATE
Authorized Official - Phone:503-482-2400
Mailing Address - Street 1:8420 N IVANHOE ST # 83811
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97203-4826
Mailing Address - Country:US
Mailing Address - Phone:503-482-2400
Mailing Address - Fax:
Practice Address - Street 1:8420 N IVANHOE ST # 83811
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97203-4826
Practice Address - Country:US
Practice Address - Phone:503-482-2400
Practice Address - Fax:503-689-8481
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-27
Last Update Date:2021-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty