Basic Information
| Provider Information | |||||||||
| NPI: | 1336401017 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TRILLIUM FAMILY SERVICES | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | WAKE ROBIN | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 3415 SE POWELL BOULEVARD | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032054362 | ||||||||
| FaxNumber: | 5032050193 | ||||||||
| Practice Location | |||||||||
| Address1: | 1520 PLAZA STREET NW | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032054362 | ||||||||
| FaxNumber: | 5032050193 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2012 | ||||||||
| LastUpdateDate: | 03/24/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | VENZKE | ||||||||
| AuthorizedOfficialFirstName: | SUZY | ||||||||
| AuthorizedOfficialMiddleName: | K | ||||||||
| AuthorizedOfficialTitleorPosition: | BILLING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 5032054362 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | TRILLIUM FAMILY SERVICES | ||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 145946 | 05 | OR | MEDICAID |