Provider Demographics
NPI:1689100117
Name:THE TRAUMA ACADEMY NORTHWEST, LLC
Entity Type:Organization
Organization Name:THE TRAUMA ACADEMY NORTHWEST, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ABRAHAM
Authorized Official - Middle Name:
Authorized Official - Last Name:REICHLIN
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:503-910-6395
Mailing Address - Street 1:2425 13TH ST SE BLDG B
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302-2545
Mailing Address - Country:US
Mailing Address - Phone:971-301-2061
Mailing Address - Fax:
Practice Address - Street 1:2425 13TH ST SE BLDG B
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-2545
Practice Address - Country:US
Practice Address - Phone:971-301-2061
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-03
Last Update Date:2017-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL57741041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty