Provider Demographics
NPI:1306987128
Name:TRILLIUM FAMILY SERVICES
Entity type:Organization
Organization Name:TRILLIUM FAMILY SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACCESS THERAPIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:DONNELLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-813-7744
Mailing Address - Street 1:3550 SE WOODWARD ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97202-1552
Mailing Address - Country:US
Mailing Address - Phone:503-234-7532
Mailing Address - Fax:
Practice Address - Street 1:3550 SE WOODWARD ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97202-1552
Practice Address - Country:US
Practice Address - Phone:503-234-7532
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-12
Last Update Date:2008-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR323P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR313312Medicaid