Provider Demographics
NPI:1407306913
Name:IMAGINE LIFE COUNSELING AND CONSULTATION, LLC.
Entity Type:Organization
Organization Name:IMAGINE LIFE COUNSELING AND CONSULTATION, LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER / THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:DEAH
Authorized Official - Middle Name:RENEE
Authorized Official - Last Name:PARTAK
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW, CADCII, ACS
Authorized Official - Phone:503-701-2294
Mailing Address - Street 1:2325 E BURNSIDE ST
Mailing Address - Street 2:SUITE 202
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-1655
Mailing Address - Country:US
Mailing Address - Phone:503-701-2294
Mailing Address - Fax:
Practice Address - Street 1:2325 E BURNSIDE ST
Practice Address - Street 2:SUITE 202
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214-1655
Practice Address - Country:US
Practice Address - Phone:503-701-2294
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-07
Last Update Date:2016-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR11-06-94101YA0400X
ORL45761041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty