Healthcare Provider Details

I. General information

NPI: 1740195130
Provider Name (Legal Business Name): RAE OF LIGHT THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/18/2026
Last Update Date: 08/18/2026
Certification Date: 08/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4145 SW WATSON CENTRAL BEAVERTON SUITE 350
BEAVERTON OR
97005
US

IV. Provider business mailing address

4145 SW WATSON CENTRAL BEAVERTON SUITE 350
BEAVERTON OR
97005
US

V. Phone/Fax

Practice location:
  • Phone: 503-332-4520
  • Fax:
Mailing address:
  • Phone: 503-332-4520
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name: EWELL DONTE EWELL
Title or Position: CEO
Credential:
Phone: 503-332-4520