Rustic Sage LLC

Primary specialty

Clinical Social WorkerTaxonomy code 1041C0700X

Legal business name

RUSTIC SAGE LLC

Doing business as

Rustic Sage LLC

Practice address

1220 SW Morrison St Ste 730
Portland, OR 97205-2226

Phone

(503) 860-1213

Fax

(844) 889-4937

NPI assigned

Nov 16, 2021

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Andre B Pruitt, LCSWNPI 1205988532

Title

Owner

Phone

(503) 860-1213

Specialties & licenses 1

Addresses

Other identifiers 1

Other names 1

• Rustic Sage LLC Doing business as

Locations

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

• Andre B Pruitt, PH.D., MSW

  • Clinical Social Worker
  • Portland, OR
  • NPI 1205988532
  NPD Authorized official

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1637020800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1718841600000",
    "number": "1861158610",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 4162",
            "city": "PORTLAND",
            "state": "OR",
            "postal_code": "972084162",
            "telephone_number": "503-860-1213",
            "fax_number": "844-889-4937"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1220 SW MORRISON ST STE 730",
            "city": "PORTLAND",
            "state": "OR",
            "postal_code": "972052226",
            "telephone_number": "503-860-1213",
            "fax_number": "844-889-4937"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "RUSTIC SAGE LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2021-11-16",
        "last_updated": "2024-06-20",
        "certification_date": "2024-06-20",
        "status": "A",
        "authorized_official_last_name": "PRUITT",
        "authorized_official_first_name": "ANDRE",
        "authorized_official_middle_name": "B",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "503-860-1213",
        "authorized_official_credential": "LCSW"
    },
    "taxonomies": [
        {
            "code": "1041C0700X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Social Worker, Clinical",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "500674262",
            "state": "OR"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Rustic Sage LLC",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Rustic Sage LLC",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Larry Russock
• Bethany Russotto, PA-C
• Chloe Rust
• Randee L Rust, LMT
• Marivic Rustia
• Susan Rustvold, DMD
• Flavius Rusu
• Claire Levesque Rusunen, PSY.D.
• Rob Rusunen
• Amy Ruth, M.D.

• Clinical Social Worker in Portland, OR
• Providers in Portland, OR by specialty
• Clinical Social Worker in Oregon

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 20, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.