Basic Information
| Provider Information | |||||||||
| NPI: | 1760779094 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RAYMOND | ||||||||
| FirstName: | REBECCA | ||||||||
| MiddleName: | |||||||||
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| Credential: | MA, QMHP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3007 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972083007 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1312 SW WASHINGTON ST | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972052327 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5035351150 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2011 | ||||||||
| LastUpdateDate: | 07/07/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | Y | Behavioral Health & Social Service Providers | Counselor | 101YA0400X | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YM0800X | N | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.