Provider Demographics
NPI:1093474132
Name:SISU HEALING PARTNERS
Entity Type:Organization
Organization Name:SISU HEALING PARTNERS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FOUNDER & DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:TARA
Authorized Official - Middle Name:
Authorized Official - Last Name:RAYBURN
Authorized Official - Suffix:
Authorized Official - Credentials:LICSWA, QMHP,CADCIII
Authorized Official - Phone:971-645-0148
Mailing Address - Street 1:1722 NW RALEIGH ST UNIT 410
Mailing Address - Street 2:MAILBOX 304
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97209
Mailing Address - Country:US
Mailing Address - Phone:503-847-9836
Mailing Address - Fax:
Practice Address - Street 1:1722 NW RALEIGH ST SPC 410
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97209-1754
Practice Address - Country:US
Practice Address - Phone:503-847-9836
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-12-16
Last Update Date:2021-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1134584527OtherNPI NUMBER