Provider Demographics
NPI:1558875476
Name:PORTLAND NEUROFEEDBACK, LLC
Entity Type:Organization
Organization Name:PORTLAND NEUROFEEDBACK, LLC
Other - Org Name:THE PATH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:GAIL
Authorized Official - Middle Name:
Authorized Official - Last Name:WOUNG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:971-940-2601
Mailing Address - Street 1:4035 NE SANDY BLVD STE 240
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97212-5331
Mailing Address - Country:US
Mailing Address - Phone:971-940-2601
Mailing Address - Fax:971-275-1534
Practice Address - Street 1:4035 NE SANDY BLVD # 200
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97212-5331
Practice Address - Country:US
Practice Address - Phone:971-940-2601
Practice Address - Fax:971-275-1534
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-30
Last Update Date:2022-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500738886Medicaid
OR5006392224Medicaid