Provider Demographics
NPI:1477391878
Name:DE LA TORRE, JOSE LUIS JR (MA)
Entity type:Individual
Prefix:MR
First Name:JOSE
Middle Name:LUIS
Last Name:DE LA TORRE
Suffix:JR
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6200 SE KING RD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97222-2891
Mailing Address - Country:US
Mailing Address - Phone:503-546-6377
Mailing Address - Fax:
Practice Address - Street 1:1312 E POWELL BLVD
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-8003
Practice Address - Country:US
Practice Address - Phone:503-546-6377
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-18
Last Update Date:2024-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR93-0841022175T00000X, 405300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes405300000XOther Service ProvidersPrevention Professional
No175T00000XOther Service ProvidersPeer Specialist