Healthcare Provider Details

I. General information

NPI: 1043814759
Provider Name (Legal Business Name): BORN TO THRIVE COUNSELING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/23/2020
Last Update Date: 11/23/2020
Certification Date: 11/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

635 SE JUNIPER CT E
GRESHAM OR
97080-7853
US

IV. Provider business mailing address

635 SE JUNIPER CT E
GRESHAM OR
97080-7853
US

V. Phone/Fax

Practice location:
  • Phone: 971-274-1419
  • Fax:
Mailing address:
  • Phone: 971-274-1419
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: TONI JACOBSON
Title or Position: OWNER/OPERATOR
Credential:
Phone: 971-274-1419