Provider Demographics
NPI:1598201519
Name:WHOLE LIFE THERAPY
Entity Type:Organization
Organization Name:WHOLE LIFE THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:COLLEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:BURKE-SIVERS
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:503-250-3123
Mailing Address - Street 1:1744 NE 42ND AVE STE A
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97213-1537
Mailing Address - Country:US
Mailing Address - Phone:503-250-3123
Mailing Address - Fax:541-631-2602
Practice Address - Street 1:1744 NE 42ND AVE STE A
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-1537
Practice Address - Country:US
Practice Address - Phone:503-250-3123
Practice Address - Fax:541-631-2602
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-13
Last Update Date:2017-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC4272101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty