Provider Demographics
NPI:1982489951
Name:PURE LIFE COUNSELING, LLC
Entity Type:Organization
Organization Name:PURE LIFE COUNSELING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MENTAL HEALTH CLINICIAN
Authorized Official - Prefix:
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:
Authorized Official - Last Name:FENNIMORE
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:503-428-2948
Mailing Address - Street 1:2860 WINTER ST SE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302-3155
Mailing Address - Country:US
Mailing Address - Phone:503-428-2948
Mailing Address - Fax:
Practice Address - Street 1:494 STATE ST STE 270
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-3647
Practice Address - Country:US
Practice Address - Phone:503-583-2121
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-08-29
Last Update Date:2023-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1417567983Medicaid
OR1881094324Medicaid