# RUSTIC SAGE LLC

> Is this information incorrect? This page shows public data from NPPES. Update your record in NPPES and this page will update automatically within 7 days. [Update your NPPES record](https://nppes.cms.hhs.gov)

- **Entity:** Organization
- **Status:** Active
- **Other names:** Rustic Sage LLC
- **Organization subpart:** No

## Provider details

- **NPI number:** 1861158610
- **Authorized official:** ANDRE B PRUITT LCSW (OWNER)
- **Authorized official phone:** (503) 860-1213

## Contact information

- **Practice address:** 1220 SW MORRISON ST STE 730, PORTLAND, OR 97205-2226
- **Practice address phone:** (503) 860-1213
- **Practice address fax:** (844) 889-4937
- **Mailing address:** PO BOX 4162, PORTLAND, OR 97208-4162
- **Mailing address phone:** (503) 860-1213
- **Mailing address fax:** (844) 889-4937

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 1041C0700X | Clinical Social Worker | — | NULL | Yes |
| 1041C0700X | Clinical Social Worker | — | — | Yes |

## Other

- **Enumeration date:** 11/16/2021
- **Last updated:** 06/20/2024