Provider Demographics
NPI:1407375801
Name:AT HOME PSYCHIATRY LLC
Entity Type:Organization
Organization Name:AT HOME PSYCHIATRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MINDY
Authorized Official - Middle Name:MILAR
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:PMHNP
Authorized Official - Phone:888-667-6467
Mailing Address - Street 1:8959 SW BARBUR BLVD STE 115
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97219-4032
Mailing Address - Country:US
Mailing Address - Phone:888-667-6467
Mailing Address - Fax:888-667-6467
Practice Address - Street 1:7975 SW 83RD AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97223-7334
Practice Address - Country:US
Practice Address - Phone:888-667-6467
Practice Address - Fax:888-667-6467
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-17
Last Update Date:2019-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200850112NP251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500623422Medicaid