Provider Demographics
NPI:1124766324
Name:SOMRAK, THERESA
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:SOMRAK
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5441 S MACADAM AVE STE N
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-6106
Mailing Address - Country:US
Mailing Address - Phone:503-308-8684
Mailing Address - Fax:503-919-2010
Practice Address - Street 1:5441 S MACADAM AVE STE N
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-6106
Practice Address - Country:US
Practice Address - Phone:503-308-8684
Practice Address - Fax:503-919-2010
Is Sole Proprietor?:No
Enumeration Date:2022-05-26
Last Update Date:2025-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC9517101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health