Provider Demographics
NPI:1083154637
Name:MINDFUL AWAKENINGS, LLC
Entity Type:Organization
Organization Name:MINDFUL AWAKENINGS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER/OWNER
Authorized Official - Prefix:MISS
Authorized Official - First Name:RYANN
Authorized Official - Middle Name:MISHELL
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:503-706-8413
Mailing Address - Street 1:4324 NE 57TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97218-2241
Mailing Address - Country:US
Mailing Address - Phone:912-381-5898
Mailing Address - Fax:
Practice Address - Street 1:4511 SE HAWTHORNE BLVD
Practice Address - Street 2:SUITE 204
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97215-3182
Practice Address - Country:US
Practice Address - Phone:503-706-8413
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-01
Last Update Date:2017-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR5355251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health