Provider Demographics
NPI:1689174757
Name:SPROUL, KURT WOODRUFF (PCA, APCC, ACMHC)
Entity type:Individual
Prefix:
First Name:KURT
Middle Name:WOODRUFF
Last Name:SPROUL
Suffix:
Gender:M
Credentials:PCA, APCC, ACMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2355 STATE ST STE 101
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-4541
Mailing Address - Country:US
Mailing Address - Phone:323-636-6135
Mailing Address - Fax:801-206-3869
Practice Address - Street 1:MINDFUL THERAPY GROUP
Practice Address - Street 2:5440 SW WESTGATE DR, SUITE 350
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239
Practice Address - Country:US
Practice Address - Phone:425-678-6463
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-15
Last Update Date:2025-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YA0400X
UT13147561-6009101YM0800X
CA13095101YM0800X
ORR10553101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)