MEDICARE: CHRYSALIS WELLNESS LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1366322935
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHRYSALIS WELLNESS LLC

Provider Business Mailing Address
First Line	:	4659 NE AINSWORTH ST
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97218-1849
Country	:	US
Telephone Number	:	503-451-0079
Fax Number	:	503-486-3527

Provider Business Practice Location Address
First Line	:	4659 NE AINSWORTH ST
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97218-1849
Country	:	US
Telephone Number	:	503-451-0079
Fax Number	:	503-486-3527

Authorized Official
Title or Position	:	OWNER
Name	:	AJNA RAE
Credential	:
Telephone Number	:	503-451-0079

Provider Enumeration Date	:	09/04/2025
Last Update Date	:	09/04/2025

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Directions to “CHRYSALIS WELLNESS LLC ” Practice Location

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