Provider Demographics
NPI:1467979914
Name:AWAKENED HEART PDX, LLC
Entity Type:Organization
Organization Name:AWAKENED HEART PDX, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, MARRIAGE & FAMILY THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:ANN MARIE
Authorized Official - Middle Name:
Authorized Official - Last Name:MCHENRY
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:971-407-3930
Mailing Address - Street 1:1306 NW HOYT ST STE 407
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97209-2787
Mailing Address - Country:US
Mailing Address - Phone:971-407-3930
Mailing Address - Fax:
Practice Address - Street 1:1306 NW HOYT ST STE 407
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97209-2787
Practice Address - Country:US
Practice Address - Phone:971-407-3930
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:AWAKENED HEART PDX, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-08-25
Last Update Date:2022-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORT1051261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
1477854750OtherNPI TYPE 1
1609295682OtherNPI
OR1134628571OtherNPI TYPE 1