Provider Demographics
NPI:1235753138
Name:OR MC SPROUT 1 LLC
Entity Type:Organization
Organization Name:OR MC SPROUT 1 LLC
Other - Org Name:SPROUT THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:YURY
Authorized Official - Middle Name:
Authorized Official - Last Name:YAKUBCHYK
Authorized Official - Suffix:SR
Authorized Official - Credentials:
Authorized Official - Phone:786-210-8200
Mailing Address - Street 1:10260 SW GREENBURG RD FL 4
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97223-5500
Mailing Address - Country:US
Mailing Address - Phone:833-991-7193
Mailing Address - Fax:929-384-7193
Practice Address - Street 1:10260 SW GREENBURG RD FL 4
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97223-5500
Practice Address - Country:US
Practice Address - Phone:833-991-7193
Practice Address - Fax:929-384-7193
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-05
Last Update Date:2021-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty