Provider Demographics
NPI:1568028975
Name:MERCURAL, TODD (PLMHP, LPC-INTERN)
Entity Type:Individual
Prefix:
First Name:TODD
Middle Name:
Last Name:MERCURAL
Suffix:
Gender:M
Credentials:PLMHP, LPC-INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2545 NE 25TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97212-4839
Mailing Address - Country:US
Mailing Address - Phone:503-389-0550
Mailing Address - Fax:
Practice Address - Street 1:2545 NE 25TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97212-4839
Practice Address - Country:US
Practice Address - Phone:503-389-0550
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-13
Last Update Date:2024-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
NE11838101YM0800X
ORR6234101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health