Provider Demographics
NPI:1811531262
Name:MIRROR POND COUNSELING LLC
Entity type:Organization
Organization Name:MIRROR POND COUNSELING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:DREW
Authorized Official - Suffix:
Authorized Official - Credentials:MA, LPC
Authorized Official - Phone:541-668-7558
Mailing Address - Street 1:754 NW BROADWAY ST STE 207
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97703-2776
Mailing Address - Country:US
Mailing Address - Phone:541-668-7558
Mailing Address - Fax:
Practice Address - Street 1:754 NW BROADWAY ST STE 207
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97703-2776
Practice Address - Country:US
Practice Address - Phone:541-668-7558
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-29
Last Update Date:2019-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Multi-Specialty
No103TP0814XBehavioral Health & Social Service ProvidersPsychologistPsychoanalysisGroup - Multi-Specialty
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup PsychotherapyGroup - Multi-Specialty
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental HealthGroup - Multi-Specialty
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoralGroup - Multi-Specialty
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & BehavioralGroup - Multi-Specialty
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamilyGroup - Multi-Specialty