Healthcare Provider Details

I. General information

NPI: 1043122567
Provider Name (Legal Business Name): VIBRANT LIFE THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/21/2026
Last Update Date: 09/21/2026
Certification Date: 09/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2842 SHIRLEY ST
EUGENE OR
97404-1881
US

IV. Provider business mailing address

1498 E MAIN ST STE 103 PMB 277
COTTAGE GROVE OR
97424
US

V. Phone/Fax

Practice location:
  • Phone: 541-597-9113
  • Fax:
Mailing address:
  • Phone: 541-597-9113
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: MRS. MINAH CLARK
Title or Position: OWNER/MENTAL HEALTH THERAPIST
Credential: LCSW
Phone: 310-488-8281