Provider Demographics
NPI:1689715666
Name:RACIES, PHILLIP G (LMFT)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:G
Last Name:RACIES
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7015 SE LAFAYETTE ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97206-2535
Mailing Address - Country:US
Mailing Address - Phone:415-686-9822
Mailing Address - Fax:503-234-6338
Practice Address - Street 1:4410 NE GLISAN ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213
Practice Address - Country:US
Practice Address - Phone:503-384-2180
Practice Address - Fax:503-234-6338
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-10
Last Update Date:2019-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORT1367106H00000X
CA51205101YM0800X
CA48815106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health