Provider Demographics
NPI:1376024695
Name:OREGON TRUAMA CENTER
Entity Type:Organization
Organization Name:OREGON TRUAMA CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THERAPIST
Authorized Official - Prefix:DR
Authorized Official - First Name:TEREK
Authorized Official - Middle Name:
Authorized Official - Last Name:KANSO
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD LPC
Authorized Official - Phone:503-866-9688
Mailing Address - Street 1:10127 SW 59TH PL
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97219-5708
Mailing Address - Country:US
Mailing Address - Phone:503-866-9688
Mailing Address - Fax:
Practice Address - Street 1:5 CENTERPOINTE DR STE 400
Practice Address - Street 2:
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97035-8661
Practice Address - Country:US
Practice Address - Phone:503-866-9688
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-24
Last Update Date:2018-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC4721261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)