Healthcare Provider Details

I. General information

NPI: 1720934896
Provider Name (Legal Business Name): AUDACIOUS LIVING THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/10/2026
Last Update Date: 03/10/2026
Certification Date: 03/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

258 E 10TH AVE
EUGENE OR
97401-3255
US

IV. Provider business mailing address

32316 GODDARD LN
COTTAGE GROVE OR
97424-9325
US

V. Phone/Fax

Practice location:
  • Phone: 542-913-1153
  • Fax:
Mailing address:
  • Phone: 541-913-1153
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MORGAN ELIZABETH WARDWELL
Title or Position: OWNER
Credential: LCSW
Phone: 541-913-1153