Provider Demographics
NPI:1922552363
Name:WE RISE, LLC
Entity Type:Organization
Organization Name:WE RISE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:JUANITA
Authorized Official - Middle Name:RENE
Authorized Official - Last Name:TUCKER
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:503-317-4240
Mailing Address - Street 1:4216 NE RODNEY AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97211-3428
Mailing Address - Country:US
Mailing Address - Phone:503-317-4240
Mailing Address - Fax:
Practice Address - Street 1:3311 NE MLK JR BLVD
Practice Address - Street 2:104
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97212-2086
Practice Address - Country:US
Practice Address - Phone:503-317-4240
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-13
Last Update Date:2016-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL4517251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500664189Medicaid
OR500664189Medicaid