Basic Information
| Provider Information | |||||||||
| NPI: | 1992873004 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TRILLIUM FAMILY SERVICES | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | CHILDREN'S FARM HOME | ||||||||
| 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: | 4455 NE HIGHWAY 20 | ||||||||
| Address2: | |||||||||
| City: | CORVALLIS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97330 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032054362 | ||||||||
| FaxNumber: | 5032050193 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/30/2006 | ||||||||
| LastUpdateDate: | 03/24/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | VENZKE | ||||||||
| AuthorizedOfficialFirstName: | SUZY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | BILLING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 5032054362 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 322D00000X | OR | N | Residential Treatment Facilities | Residential Treatment Facility, Emotionally Disturbed Children | 323P00000X | OR | N | Residential Treatment Facilities | Psychiatric Residential Treatment Facility | 385HR2055X | OR | N | Respite Care Facility | Respite Care | Respite Care, Mental Illness, Child | 323P00000X | N | Residential Treatment Facilities | Psychiatric Residential Treatment Facility | 385HR2055X | N | Respite Care Facility | Respite Care | Respite Care, Mental Illness, Child | 322D00000X | Y | Residential Treatment Facilities | Residential Treatment Facility, Emotionally Disturbed Children |
ID Information
| ID | Type | State | Issuer | Description | 312089 | 05 | OR | MEDICAID |