Healthcare Provider Details

I. General information

NPI: 1891109617
Provider Name (Legal Business Name): MELODY LARSEN LMFT, LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MELODY BRENNEISEN M.S.

II. Dates (important events)

Enumeration Date: 06/19/2014
Last Update Date: 10/07/2026
Certification Date: 10/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5441 S MACADAM AVE # 6632
PORTLAND OR
97239-6106
US

IV. Provider business mailing address

5441 S MACADAM AVE # 6632
PORTLAND OR
97239-6106
US

V. Phone/Fax

Practice location:
  • Phone: 503-308-8216
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberBBH-LCPC-LIC-38841
License Number StateMT
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberBBH-LMFT-LIC-38685
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: