Healthcare Provider Details

I. General information

NPI: 1295885069
Provider Name (Legal Business Name): HEATHER LOUISE MIRASOL M.A., LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/11/2007
Last Update Date: 06/29/2025
Certification Date: 06/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

649 NE HOOD AVE
GRESHAM OR
97030-7328
US

IV. Provider business mailing address

1201 SE 223RD AVE STE 165
GRESHAM OR
97030-2577
US

V. Phone/Fax

Practice location:
  • Phone: 971-404-4668
  • Fax: 971-273-2708
Mailing address:
  • Phone: 971-404-4668
  • Fax: 971-273-2708

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberC2670
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: