Healthcare Provider Details

I. General information

NPI: 1124637236
Provider Name (Legal Business Name): INNER LIGHT COUNSELING & BODYWORK LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/24/2020
Last Update Date: 07/24/2020
Certification Date: 07/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2520 CHAUCER CT
EUGENE OR
97405-1217
US

IV. Provider business mailing address

2520 CHAUCER CT
EUGENE OR
97405-1217
US

V. Phone/Fax

Practice location:
  • Phone: 541-203-6703
  • Fax: 541-229-1209
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: AMALIA E SULLIVAN
Title or Position: OWNER
Credential: LCSW
Phone: 541-203-6703