| Create Change, Llc | |
|
312 Nw 10th Ave Suite 200 Portland OR 97209-3121 | |
| (503) 842-7855 | |
| (503) 222-0984 |
| Full Name | Create Change, Llc |
|---|---|
| Speciality | Social Worker |
| Location | 312 Nw 10th Ave, Portland, Oregon |
| Authorized Official Name and Position | Sheila Walty (DIRECTOR) |
| Authorized Official Contact | 5038427855 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Create Change, Llc 312 Nw 10th Ave Suite 200 Portland OR 97209-3121 Ph: (503) 842-7855 | Create Change, Llc 312 Nw 10th Ave Suite 200 Portland OR 97209-3121 Ph: (503) 842-7855 |
| NPI Number | 1407210867 |
|---|---|
| Provider Enumeration Date | 04/11/2016 |
| Last Update Date | 04/11/2016 |
| Medicare PECOS PAC ID | 8921385840 |
|---|---|
| Medicare Enrollment ID | O20170502002394 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1407210867 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 1041C0700X | Social Worker - Clinical | 2340 (Oregon) | Primary |
| Provider Name | Sheila M Walty |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1407863947 PECOS PAC ID: 2961509831 Enrollment ID: I20070530000109 |
| Provider Name | Mindy M Moore |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1174792998 PECOS PAC ID: 4183867260 Enrollment ID: I20130821001042 |
| Provider Name | Sarah J Notton |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1194065250 PECOS PAC ID: 7315232394 Enrollment ID: I20160830001680 |
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