Provider Demographics
NPI:1780221499
Name:COLLECTIVE CARE CLINIC, LLC
Entity Type:Organization
Organization Name:COLLECTIVE CARE CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST / OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JILL
Authorized Official - Middle Name:ASHLEY
Authorized Official - Last Name:DAVIDSON
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:503-313-0028
Mailing Address - Street 1:1130 SW MORRISON ST STE 619
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97205-2217
Mailing Address - Country:US
Mailing Address - Phone:503-313-0028
Mailing Address - Fax:
Practice Address - Street 1:1130 SW MORRISON ST STE 619
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97205-2217
Practice Address - Country:US
Practice Address - Phone:503-313-0028
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-02
Last Update Date:2019-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & BehavioralGroup - Single Specialty