Organization
GATEWAY TO REJUVENATION
Active
Organization subpart
No
Provider details
NPI number
Authorized official
OMOLOLA A ELLIOTT LCSW (THERAPIST)
(971) 212-3146
Entity
Organization
Contact information
Practice address
1312 E BURNSIDE ST, PORTLAND, OR 97214-1424
(503) 205-1669
Mailing address
3439 NE SANDY BLVD STE 216, PORTLAND, OR 97232-1959
(503) 205-1669
Taxonomy
Speciality
Code
Description
License number
State
251S00000X
Community/Behavioral Health Agency
Primary
L7113
OR
Other
Enumeration date
04/03/2017
Last updated
04/03/2017
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