Healthcare Provider Details

I. General information

NPI: 1083374805
Provider Name (Legal Business Name): CAROLYN WATERFALL MS LPC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/20/2021
Last Update Date: 12/21/2021
Certification Date: 12/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

704 MAIN ST STE 305-8
OREGON CITY OR
97045-9704
US

IV. Provider business mailing address

12332 SW 72ND AVE STE 113
PORTLAND OR
97223
US

V. Phone/Fax

Practice location:
  • Phone: 503-686-3918
  • Fax: 503-624-6352
Mailing address:
  • Phone: 503-686-3918
  • Fax: 503-624-6352

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: CAROLYN WATERFALL
Title or Position: OWNER/COUNSELOR
Credential: LPC
Phone: 503-686-3918