Provider Demographics
NPI:1417291212
Name:INTEGRATIVE TRAUMA TREATMENT CENTER, LLC
Entity Type:Organization
Organization Name:INTEGRATIVE TRAUMA TREATMENT CENTER, LLC
Other - Org Name:VANCOUVER INTEGRATIVE COUNSELING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ATHENA
Authorized Official - Middle Name:
Authorized Official - Last Name:PHILLIPS
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:503-819-4181
Mailing Address - Street 1:811 NW 19TH AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97209-1401
Mailing Address - Country:US
Mailing Address - Phone:971-266-6910
Mailing Address - Fax:888-972-3623
Practice Address - Street 1:811 NW 19TH AVE STE 102
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97209-1401
Practice Address - Country:US
Practice Address - Phone:971-266-6910
Practice Address - Fax:888-972-3623
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:INTEGRATIVE TRAUMA TREATMENT CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-11-16
Last Update Date:2015-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL44621041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty