Provider Demographics
NPI:1427659549
Name:HEISLER, RIVER J
Entity type:Individual
Prefix:
First Name:RIVER
Middle Name:J
Last Name:HEISLER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 NE MARTIN LUTHER KING JR BLVD STE 203
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97232-3579
Mailing Address - Country:US
Mailing Address - Phone:971-350-1122
Mailing Address - Fax:
Practice Address - Street 1:11 NE MARTIN LUTHER KING JR BLVD STE 203
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232-3579
Practice Address - Country:US
Practice Address - Phone:971-350-1122
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-04
Last Update Date:2024-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1811042872Medicaid