Basic Information
| Provider Information | |||||||||
| NPI: | 1821299033 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TRILLIUM FAMILY SERVICES | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | PARRY CENTER FOR CHILDREN | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 3415 SE POWELL BLVD. | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032054362 | ||||||||
| FaxNumber: | 5032050193 | ||||||||
| Practice Location | |||||||||
| Address1: | 3415 SE POWELL BLVD. | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032054362 | ||||||||
| FaxNumber: | 5032050193 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/29/2007 | ||||||||
| LastUpdateDate: | 07/10/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | VENZKE | ||||||||
| AuthorizedOfficialFirstName: | SUZY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | BILLING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 5032054362 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 320800000X | N | Residential Treatment Facilities | Community Based Residential Treatment Facility, Mental Illness | 251S00000X | 022640 | OR | N | Agencies | Community/Behavioral Health | 320800000X | 022640 | OR | Y | Residential Treatment Facilities | Community Based Residential Treatment Facility, Mental Illness |
ID Information
| ID | Type | State | Issuer | Description | 022640 | 05 | OR | MEDICAID |