Provider Demographics
NPI:1144901513
Name:EVOLVING SELF INTEGRAL COUNSELING, LLC
Entity type:Organization
Organization Name:EVOLVING SELF INTEGRAL COUNSELING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROFESSIONAL COUNSELING ASSOCIATE
Authorized Official - Prefix:
Authorized Official - First Name:PALMA AZUCENA
Authorized Official - Middle Name:
Authorized Official - Last Name:CORRAL SOTELO
Authorized Official - Suffix:
Authorized Official - Credentials:PCA
Authorized Official - Phone:503-310-6276
Mailing Address - Street 1:2232 NW EVERETT ST APT 21
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97210-5516
Mailing Address - Country:US
Mailing Address - Phone:503-310-6276
Mailing Address - Fax:
Practice Address - Street 1:2232 NW EVERETT ST APT 21
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210-5516
Practice Address - Country:US
Practice Address - Phone:503-310-6276
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-07-28
Last Update Date:2023-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health