Provider Demographics
NPI:1265039564
Name:EMBODIED LIFE THERAPY CENTER LLC
Entity Type:Organization
Organization Name:EMBODIED LIFE THERAPY CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:DODD
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:971-266-1081
Mailing Address - Street 1:6906 N RICHARDS ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97203-6138
Mailing Address - Country:US
Mailing Address - Phone:971-336-0338
Mailing Address - Fax:
Practice Address - Street 1:6906 N RICHARDS ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97203-6138
Practice Address - Country:US
Practice Address - Phone:971-336-0338
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-08
Last Update Date:2021-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty