Healthcare Provider Details

I. General information

NPI: 1275205379
Provider Name (Legal Business Name): BEAN BAG THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/28/2021
Last Update Date: 09/28/2021
Certification Date: 09/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 6TH ST
FAIRVIEW OR
97024-1941
US

IV. Provider business mailing address

25 6TH ST
FAIRVIEW OR
97024-1941
US

V. Phone/Fax

Practice location:
  • Phone: 818-579-2029
  • Fax:
Mailing address:
  • Phone: 818-579-2029
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: MRS. LISA PEACOCK MCLAUGHLIN
Title or Position: SOLE PROPRIETOR/ONLY MEMBER
Credential: LMFT
Phone: 818-579-2029