Healthcare Provider Details

I. General information

NPI: 1588249692
Provider Name (Legal Business Name): WISHING WELLNESS COUNSELING AND COACHING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/11/2021
Last Update Date: 03/11/2021
Certification Date: 03/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

406 NE 4TH ST STE 114
GRESHAM OR
97030-7496
US

IV. Provider business mailing address

406 NE 4TH ST STE 114
GRESHAM OR
97030-7496
US

V. Phone/Fax

Practice location:
  • Phone: 503-803-9323
  • Fax: 503-674-9740
Mailing address:
  • Phone: 503-803-9323
  • Fax: 503-674-9740

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: STEPHANIE GALLIAN
Title or Position: OWNER/OPERATOR
Credential: LCSW
Phone: 503-803-9323