Healthcare Provider Details

I. General information

NPI: 1871069674
Provider Name (Legal Business Name): PORCHLIGHT CUSTOM COUNSELING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/18/2018
Last Update Date: 10/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

455 S KNOTT ST
CANBY OR
97013-4426
US

IV. Provider business mailing address

PO BOX 344
TURNER OR
97392-0344
US

V. Phone/Fax

Practice location:
  • Phone: 503-395-3301
  • Fax:
Mailing address:
  • Phone: 503-395-3301
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: MICA RICHARDS
Title or Position: PART OWNER
Credential: LMHC
Phone: 503-395-3301