Provider Demographics
NPI:1134502990
Name:THE CREATIVE WELLNESS STUDIO
Entity Type:Organization
Organization Name:THE CREATIVE WELLNESS STUDIO
Other - Org Name:AUTOPOIETICA: THE CREATIVE WELLNESS STUDIO
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:THERAPIST/PARTNER
Authorized Official - Prefix:MS
Authorized Official - First Name:HALLORY
Authorized Official - Middle Name:
Authorized Official - Last Name:MOGREN
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:971-645-4499
Mailing Address - Street 1:833 SE MAIN ST
Mailing Address - Street 2:DEPARTMENT 210
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-3454
Mailing Address - Country:US
Mailing Address - Phone:971-645-4499
Mailing Address - Fax:971-645-4820
Practice Address - Street 1:833 SE MAIN ST # 405
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214-3454
Practice Address - Country:US
Practice Address - Phone:971-645-4499
Practice Address - Fax:971-645-4820
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-29
Last Update Date:2015-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC3680101YM0800X
ORA36061041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty