Healthcare Provider Details

I. General information

NPI: 1275866626
Provider Name (Legal Business Name): HEIDI BERMEOSOLO LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/16/2009
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 NW CIVIC DR STE 310
GRESHAM OR
97030-3774
US

IV. Provider business mailing address

8007 NE 61ST ST
VANCOUVER WA
98662-5467
US

V. Phone/Fax

Practice location:
  • Phone: 503-666-8832
  • Fax: 503-666-8832
Mailing address:
  • Phone: 503-349-1362
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberC3069
License Number StateOR

VII. Legacy identifiers

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: