| Rustic Sage Llc | |
|
1220 Sw Morrison St Ste 730 Portland OR 97205-2226 | |
| (503) 860-1213 | |
| (844) 889-4937 |
| Full Name | Rustic Sage Llc |
|---|---|
| Speciality | Social Worker - Clinical |
| Location | 1220 Sw Morrison St Ste 730, Portland, Oregon |
| Authorized Official Name and Position | Andre B Pruitt (OWNER) |
| Authorized Official Contact | 5038601213 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
| Rustic Sage Llc Po Box 4162 Portland OR 97208-4162 Ph: (503) 860-1213 | Rustic Sage Llc 1220 Sw Morrison St Ste 730 Portland OR 97205-2226 Ph: (503) 860-1213 |
| NPI Number | 1861158610 |
|---|---|
| Provider Enumeration Date | 11/16/2021 |
| Last Update Date | 06/20/2024 |
| Certification Date | 06/20/2024 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1861158610 | NPI | - | NPPES |
| 500674262 | Medicaid | OR |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 1041C0700X | Social Worker - Clinical | (* (Not Available)) | Primary |
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