Healthcare Provider Details

I. General information

NPI: 1053285270
Provider Name (Legal Business Name): GLACIER LILY COUNSELING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/01/2025
Last Update Date: 06/04/2026
Certification Date: 06/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

431 NW FRANKLIN AVE STE 200
BEND OR
97703-2827
US

IV. Provider business mailing address

431 NW FRANKLIN AVE STE 200
BEND OR
97703-2827
US

V. Phone/Fax

Practice location:
  • Phone: 541-834-9068
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name: MARYAM MIRAHMADI
Title or Position: MEMBER/OWNER
Credential: LPC
Phone: 541-834-9068