Provider Demographics
NPI:1851042279
Name:CONNECT THRIVE THERAPY, LLC
Entity Type:Organization
Organization Name:CONNECT THRIVE THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:PHELPS
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:971-339-1662
Mailing Address - Street 1:PO BOX 2044
Mailing Address - Street 2:
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97035-0631
Mailing Address - Country:US
Mailing Address - Phone:971-339-1662
Mailing Address - Fax:
Practice Address - Street 1:4800 MEADOWS RD STE 320
Practice Address - Street 2:
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97035-4264
Practice Address - Country:US
Practice Address - Phone:971-339-1662
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-18
Last Update Date:2022-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health