Provider Demographics
NPI:1205573433
Name:TRILLO, SAMUEL AUGUST (INTERN)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:AUGUST
Last Name:TRILLO
Suffix:
Gender:M
Credentials:INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4121 N ALBINA AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97217-3001
Mailing Address - Country:US
Mailing Address - Phone:415-717-6666
Mailing Address - Fax:
Practice Address - Street 1:10572 SE WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97216-2809
Practice Address - Country:US
Practice Address - Phone:503-284-6883
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-18
Last Update Date:2024-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA390200000X
ORR9005101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program