Provider Demographics
NPI:1699205773
Name:CEMENTED ROSE THERAPEUTICS, LLC
Entity Type:Organization
Organization Name:CEMENTED ROSE THERAPEUTICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BEHAVIORAL HEALTH DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SHARNISSA
Authorized Official - Middle Name:T
Authorized Official - Last Name:SECRETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:971-227-3553
Mailing Address - Street 1:4110 NE 122ND AVE STE 115
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97230-1384
Mailing Address - Country:US
Mailing Address - Phone:971-227-3553
Mailing Address - Fax:
Practice Address - Street 1:4110 NE 122ND AVE STE 115
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97230-1384
Practice Address - Country:US
Practice Address - Phone:971-227-3553
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-12
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL69411041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty