Basic Information
| Provider Information | |||||||||
| NPI: | 1740941533 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TRILLIUM FAMILY SERVICES, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3415 SE POWELL BLVD | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972023371 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032349591 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3601 W 10TH ST | ||||||||
| Address2: | |||||||||
| City: | THE DALLES | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970584377 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032349591 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/04/2022 | ||||||||
| LastUpdateDate: | 01/04/2022 | ||||||||
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| AuthorizedOfficialLastName: | VENZKE | ||||||||
| AuthorizedOfficialFirstName: | SUZY | ||||||||
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| AuthorizedOfficialTitleorPosition: | SR. MANAGER OF BILLING SERVICES | ||||||||
| AuthorizedOfficialTelephone: | 5032054362 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | TRILLIUM FAMILY SERVICES, INC. | ||||||||
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| NPICertificationDate: | 01/04/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251C00000X | N | Agencies | Day Training, Developmentally Disabled Services | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | NONE | 05 | OR | MEDICAID |