Healthcare Provider Details

I. General information

NPI: 1356850697
Provider Name (Legal Business Name): ELEVATE WELLNESS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/28/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6700 SW 105TH AVE STE 203
BEAVERTON OR
97008-8824
US

IV. Provider business mailing address

6700 SW 105TH AVE STE 203
BEAVERTON OR
97008-8824
US

V. Phone/Fax

Practice location:
  • Phone: 503-435-7663
  • Fax:
Mailing address:
  • Phone: 503-435-7663
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License NumberR4844
License Number StateOR

VIII. Authorized Official

Name: HEATHER DENISE GLENN
Title or Position: OWNER
Credential: LPC INTERN, NCC, CRC
Phone: 541-337-6381