Provider Demographics
NPI:1407388812
Name:GATEWAY TO REJUVENATION
Entity Type:Organization
Organization Name:GATEWAY TO REJUVENATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:OMOLOLA
Authorized Official - Middle Name:A
Authorized Official - Last Name:ELLIOTT
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:971-212-3146
Mailing Address - Street 1:3439 NE SANDY BLVD STE 216
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97232-1959
Mailing Address - Country:US
Mailing Address - Phone:503-205-1669
Mailing Address - Fax:
Practice Address - Street 1:1312 E BURNSIDE ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214-1424
Practice Address - Country:US
Practice Address - Phone:503-205-1669
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-03
Last Update Date:2017-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL7113251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health