Provider Demographics
NPI:1255977021
Name:PORTLAND PSYCHIATRIC ALLIANCE LLC
Entity type:Organization
Organization Name:PORTLAND PSYCHIATRIC ALLIANCE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:TYLER
Authorized Official - Middle Name:
Authorized Official - Last Name:CHIPMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DNP
Authorized Official - Phone:503-406-6515
Mailing Address - Street 1:3434 SW KELLY AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-4630
Mailing Address - Country:US
Mailing Address - Phone:503-406-6515
Mailing Address - Fax:
Practice Address - Street 1:3434 SW KELLY AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-4630
Practice Address - Country:US
Practice Address - Phone:503-406-6515
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-11-26
Last Update Date:2019-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty