Provider Demographics
NPI:1528303476
Name:THE GREAT ESCAPE INTUITIVE THERAPIES, LLC
Entity type:Organization
Organization Name:THE GREAT ESCAPE INTUITIVE THERAPIES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ OPERATOR
Authorized Official - Prefix:
Authorized Official - First Name:CHERYL
Authorized Official - Middle Name:
Authorized Official - Last Name:GREATHOUSE
Authorized Official - Suffix:
Authorized Official - Credentials:LMT, LPC-INTERN
Authorized Official - Phone:503-944-9291
Mailing Address - Street 1:1308 NW 20TH AVE
Mailing Address - Street 2:SUITE 4
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97209-1607
Mailing Address - Country:US
Mailing Address - Phone:503-944-9291
Mailing Address - Fax:630-934-9391
Practice Address - Street 1:1308 NW 20TH AVE
Practice Address - Street 2:SUITE 4
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97209-1607
Practice Address - Country:US
Practice Address - Phone:503-944-9291
Practice Address - Fax:630-934-9391
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-04
Last Update Date:2016-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR101YM0800X
OR11951225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty