Provider Demographics
NPI:1952996076
Name:SACRED PSYCHIATRY, LLC
Entity Type:Organization
Organization Name:SACRED PSYCHIATRY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROOSEVELT
Authorized Official - Middle Name:
Authorized Official - Last Name:LEWIS
Authorized Official - Suffix:
Authorized Official - Credentials:PMHNP-BC, C-NP
Authorized Official - Phone:503-498-6455
Mailing Address - Street 1:1717 NE 42ND AVE STE 100E
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97213-1569
Mailing Address - Country:US
Mailing Address - Phone:503-498-6455
Mailing Address - Fax:
Practice Address - Street 1:1717 NE 42ND AVE STE 100E
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-1569
Practice Address - Country:US
Practice Address - Phone:503-498-6455
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-02
Last Update Date:2021-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)Group - Multi-Specialty
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty