Provider Demographics
NPI:1144425018
Name:SIX RIVERS COUNSELING
Entity Type:Organization
Organization Name:SIX RIVERS COUNSELING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:MR
Authorized Official - First Name:BRAD
Authorized Official - Middle Name:W
Authorized Official - Last Name:LEVITT
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:208-452-7190
Mailing Address - Street 1:182 SW 10TH ST
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:OR
Mailing Address - Zip Code:97914-2134
Mailing Address - Country:US
Mailing Address - Phone:208-452-7190
Mailing Address - Fax:
Practice Address - Street 1:182 SW 10TH ST
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:OR
Practice Address - Zip Code:97914-2134
Practice Address - Country:US
Practice Address - Phone:208-452-7190
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-19
Last Update Date:2008-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPSY-202138103TC0700X
ORPSY-119103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID805206300Medicaid
ID1684853Medicare ID - Type Unspecified
ID805206300Medicaid