Provider Demographics
NPI:1619418647
Name:MENTAL HEALTH & ADDICTION THERAPY, LLC
Entity Type:Organization
Organization Name:MENTAL HEALTH & ADDICTION THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MENTAL HEALTH & ADDICTION THERAPIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:NIAZ
Authorized Official - Middle Name:
Authorized Official - Last Name:LARSEN
Authorized Official - Suffix:
Authorized Official - Credentials:LPC, CADC
Authorized Official - Phone:503-804-1467
Mailing Address - Street 1:4654 N VANCOUVER AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97217-2946
Mailing Address - Country:US
Mailing Address - Phone:503-804-1467
Mailing Address - Fax:
Practice Address - Street 1:511 SW 10TH AVE STE 601
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97205-2707
Practice Address - Country:US
Practice Address - Phone:503-597-8250
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-09
Last Update Date:2017-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR11-03-20101YA0400X
ORC2855101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty