Provider Demographics
NPI:1376925339
Name:HEAL THRIVE GROW BEHAVIORAL HEALTH, INC.
Entity Type:Organization
Organization Name:HEAL THRIVE GROW BEHAVIORAL HEALTH, INC.
Other - Org Name:PORTLAND EVIDENCE BASED PSYCHOTHERAPY CLINIC, INC.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:BUSINESS OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:LOREN
Authorized Official - Middle Name:
Authorized Official - Last Name:WAMPLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-290-3290
Mailing Address - Street 1:5200 SW MACADAM AVE STE 580
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-3837
Mailing Address - Country:US
Mailing Address - Phone:503-290-3261
Mailing Address - Fax:503-231-8153
Practice Address - Street 1:5200 SW MACADAM AVE STE 155
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-3833
Practice Address - Country:US
Practice Address - Phone:503-290-3261
Practice Address - Fax:503-231-8153
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PORTLAND DBT INSTITUTE, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-06-25
Last Update Date:2016-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & BehavioralGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup PsychotherapyGroup - Multi-Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty