Provider Demographics
NPI:1053148866
Name:ILLUMINATION COUNSELING LLC
Entity type:Organization
Organization Name:ILLUMINATION COUNSELING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:GAYLE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:WAITCHES
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:503-705-8489
Mailing Address - Street 1:2922 SW 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97201-4714
Mailing Address - Country:US
Mailing Address - Phone:503-705-8489
Mailing Address - Fax:
Practice Address - Street 1:2922 SW 2ND AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97201-4714
Practice Address - Country:US
Practice Address - Phone:503-705-8489
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-09-16
Last Update Date:2024-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)