Healthcare Provider Details

I. General information

NPI: 1760250724
Provider Name (Legal Business Name): EQUIPOISE INTEGRAL COUNSELING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2023
Last Update Date: 12/19/2023
Certification Date: 12/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

ACTIVSPACE 1722 NW RALEIGH ST SUITE 201
PORTLAND OR
97209
US

IV. Provider business mailing address

821 NW 11TH AVE APT 411
PORTLAND OR
97209-3231
US

V. Phone/Fax

Practice location:
  • Phone: 503-887-3608
  • Fax: 503-809-5088
Mailing address:
  • Phone: 503-887-3608
  • Fax: 503-809-5088

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 Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code225600000X
TaxonomyDance Therapist
License Number
License Number State

VIII. Authorized Official

Name: LAVINIA PAOLA MAGLIOCCO
Title or Position: PROFESSIONAL COUNSELOR
Credential: MS CRC
Phone: 503-887-3608