Healthcare Provider Details

I. General information

NPI: 1437997145
Provider Name (Legal Business Name): PACIFIC NW MINDFUL CHANGE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/17/2024
Last Update Date: 07/14/2026
Certification Date: 07/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

541 WILLAMETTE ST STE 315
EUGENE OR
97401-2692
US

IV. Provider business mailing address

541 WILLAMETTE ST STE 315
EUGENE OR
97401-2692
US

V. Phone/Fax

Practice location:
  • Phone: 540-824-4461
  • Fax: 503-400-7452
Mailing address:
  • Phone: 540-824-4461
  • Fax: 503-400-7452

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: MICHELLE LEE RETTON
Title or Position: LCSW
Credential:
Phone: 540-824-4461