Provider Demographics
NPI:1861639312
Name:CENTER FOR BRAIN-WISE LIVING
Entity Type:Organization
Organization Name:CENTER FOR BRAIN-WISE LIVING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:BONNIE
Authorized Official - Middle Name:L
Authorized Official - Last Name:BADENOCH
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:360-601-6859
Mailing Address - Street 1:16420 SE MCGILLIVRAY BLVD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98683-3461
Mailing Address - Country:US
Mailing Address - Phone:360-601-6859
Mailing Address - Fax:360-944-2071
Practice Address - Street 1:10011 SE DIVISION ST
Practice Address - Street 2:SUITE 312
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97266-1351
Practice Address - Country:US
Practice Address - Phone:360-601-6859
Practice Address - Fax:360-944-2071
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-20
Last Update Date:2009-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR19278251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health