Healthcare Provider Details

I. General information

NPI: 1639085103
Provider Name (Legal Business Name): SOFT MOON WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/24/2026
Last Update Date: 08/24/2026
Certification Date: 08/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4768 SE 52ND AVE
PORTLAND OR
97206-4925
US

IV. Provider business mailing address

4768 SE 52ND AVE
PORTLAND OR
97206-4925
US

V. Phone/Fax

Practice location:
  • Phone: 808-640-7969
  • Fax:
Mailing address:
  • Phone: 808-640-7969
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: JULIET HIEBLER
Title or Position: MENTAL HEALTH COUNSELOR
Credential: LPC
Phone: 808-640-7969