Healthcare Provider Details

I. General information

NPI: 1003441536
Provider Name (Legal Business Name): RESTORING BALANCE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/04/2020
Last Update Date: 08/24/2020
Certification Date: 08/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12725 SW MILLIKAN WAY STE 300
BEAVERTON OR
97005-1687
US

IV. Provider business mailing address

605 NW 118TH AVE UNIT 106
PORTLAND OR
97229-6670
US

V. Phone/Fax

Practice location:
  • Phone: 503-749-9076
  • Fax:
Mailing address:
  • Phone: 503-816-9211
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MACKENSIE MARIE KEINER
Title or Position: PSYCHOTHERAPIST
Credential: MSW, CSWA, QMHP
Phone: 503-713-5040