Provider Demographics
NPI:1295453686
Name:REVERIE PSYCHOTHERAPY LLC
Entity type:Organization
Organization Name:REVERIE PSYCHOTHERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER AND SOLE MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:PRISCILLA
Authorized Official - Middle Name:
Authorized Official - Last Name:SHIM
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:503-966-2395
Mailing Address - Street 1:1500 NW BETHANY BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97006-5236
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1500 NW BETHANY BLVD STE 200
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97006-5236
Practice Address - Country:US
Practice Address - Phone:503-966-2395
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-22
Last Update Date:2022-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty