Organization
REVAMP CREATIVE, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
HEIDI PETRA DAVISSON LPC (LICENSED PROFESSIONAL COUNSELOR)
(503) 929-7750
Entity
Organization
Contact information
Practice address
4037 NE TILLAMOOK ST, PORTLAND, OR 97212-5341
(503) 929-7750
Mailing address
63 NE THOMPSON ST, PORTLAND, OR 97212-3741
(503) 929-7750
Taxonomy
Speciality
Code
Description
License number
State
101YM0800X
Mental Health Counselor
—
—
251B00000X
Case Management Agency
—
—
251S00000X
Community/Behavioral Health Agency
—
—
261QM0801X
Mental Health Clinic/Center (Including Community Mental Health Center)
—
—
261QM0850X
Adult Mental Health Clinic/Center
Primary
—
—
261QM0855X
Adolescent and Children Mental Health Clinic/Center
—
—
320800000X
Mental Illness Community Based Residential Treatment Facility
—
—
Other
Enumeration date
06/29/2023
Last updated
03/10/2025
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