Provider Demographics
NPI:1871658997
Name:NORTHSIDE FAMILY COUNSELING, INC
Entity Type:Organization
Organization Name:NORTHSIDE FAMILY COUNSELING, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:E
Authorized Official - Last Name:RAHE
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:503-543-6164
Mailing Address - Street 1:51579 COLUMBIA RIVER HWY
Mailing Address - Street 2:STE 'I'
Mailing Address - City:SCAPPOOSE
Mailing Address - State:OR
Mailing Address - Zip Code:97056-8411
Mailing Address - Country:US
Mailing Address - Phone:503-543-6164
Mailing Address - Fax:503-543-6040
Practice Address - Street 1:51579 COLUMBIA RIVER HWY
Practice Address - Street 2:STE 'I'
Practice Address - City:SCAPPOOSE
Practice Address - State:OR
Practice Address - Zip Code:97056-8411
Practice Address - Country:US
Practice Address - Phone:503-543-6164
Practice Address - Fax:503-543-6040
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-27
Last Update Date:2009-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL13301041C0700X
ORL27991041C0700X
ORT0349106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
0000WFBRYMedicare PIN