Provider Demographics
NPI:1235740929
Name:PHOENIX RISING THERAPY, LLC
Entity type:Organization
Organization Name:PHOENIX RISING THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED PSYCHOLOGIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CARA
Authorized Official - Middle Name:
Authorized Official - Last Name:FREUDENBERG
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:541-321-0788
Mailing Address - Street 1:1110 SE ALDER STREET, SUITE 301, PMB #73
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214
Mailing Address - Country:US
Mailing Address - Phone:541-321-0788
Mailing Address - Fax:541-735-9465
Practice Address - Street 1:1110 SE ALDER STREET, SUITE 301
Practice Address - Street 2:#73
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214
Practice Address - Country:US
Practice Address - Phone:541-321-0788
Practice Address - Fax:541-735-9465
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-14
Last Update Date:2024-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
1053700559OtherINDIVIDUAL NPI
OR500757076Medicaid