Provider Demographics
NPI:1609206291
Name:PACIFIC NORTHWEST BEHAVIORAL HEALTH, LLC
Entity Type:Organization
Organization Name:PACIFIC NORTHWEST BEHAVIORAL HEALTH, LLC
Other - Org Name:PNWBH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BUSINESS OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:ALISON
Authorized Official - Middle Name:CHRISTINE
Authorized Official - Last Name:GULLION
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:971-258-2120
Mailing Address - Street 1:6519 SE MILWAUKIE AVENUE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97202
Mailing Address - Country:US
Mailing Address - Phone:971-258-2120
Mailing Address - Fax:971-200-2719
Practice Address - Street 1:6519 SE MILWAUKIE AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97202-5519
Practice Address - Country:US
Practice Address - Phone:971-258-2120
Practice Address - Fax:971-200-2719
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-18
Last Update Date:2013-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC2054101YM0800X
OR163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental HealthGroup - Multi-Specialty