Provider Demographics
NPI:1629435441
Name:HEARTS MADE WHOLE COUNSELING, LLC
Entity Type:Organization
Organization Name:HEARTS MADE WHOLE COUNSELING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED PROFESSIONAL COUNSELOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:USHIRIKA
Authorized Official - Middle Name:V
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:503-906-7912
Mailing Address - Street 1:12725 SW MILLIKAN WAY STE 300
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97005-1687
Mailing Address - Country:US
Mailing Address - Phone:503-906-7912
Mailing Address - Fax:
Practice Address - Street 1:12725 SW MILLIKAN WAY STE 300
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97005-1687
Practice Address - Country:US
Practice Address - Phone:503-906-7912
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-25
Last Update Date:2016-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC3740101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty