Provider Demographics
NPI:1669830865
Name:GATHERED & WISE LLC
Entity Type:Organization
Organization Name:GATHERED & WISE LLC
Other - Org Name:HOLLY POMME MSW LCSW
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER/CLINICAL DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:HOLLY
Authorized Official - Middle Name:ELISE
Authorized Official - Last Name:POMME
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW, PMH-C
Authorized Official - Phone:541-704-7511
Mailing Address - Street 1:112 E BURNETT ST
Mailing Address - Street 2:
Mailing Address - City:STAYTON
Mailing Address - State:OR
Mailing Address - Zip Code:97383-1704
Mailing Address - Country:US
Mailing Address - Phone:541-704-7511
Mailing Address - Fax:541-325-4082
Practice Address - Street 1:112 E BURNETT ST
Practice Address - Street 2:
Practice Address - City:STAYTON
Practice Address - State:OR
Practice Address - Zip Code:97383-1704
Practice Address - Country:US
Practice Address - Phone:541-704-7511
Practice Address - Fax:541-325-4082
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-02
Last Update Date:2023-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL6179251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500797440Medicaid