Healthcare Provider Details

I. General information

NPI: 1811531262
Provider Name (Legal Business Name): MIRROR POND COUNSELING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/29/2019
Last Update Date: 10/29/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

754 NW BROADWAY ST STE 207
BEND OR
97703-2776
US

IV. Provider business mailing address

754 NW BROADWAY ST STE 207
BEND OR
97703-2776
US

V. Phone/Fax

Practice location:
  • Phone: 541-668-7558
  • Fax:
Mailing address:
  • Phone: 541-668-7558
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code103TF0000X
TaxonomyFamily Psychologist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code103TP0814X
TaxonomyPsychoanalysis Psychologist
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code103TP2701X
TaxonomyGroup Psychotherapy Psychologist
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KIMBERLY DREW
Title or Position: OWNER
Credential: MA, LPC
Phone: 541-668-7558