Healthcare Provider Details

I. General information

NPI: 1104333103
Provider Name (Legal Business Name): MANDALA MENTAL AND BEHAVIORAL HEALTH, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/29/2017
Last Update Date: 06/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 NE HOLLADAY ST STE 16001614
PORTLAND OR
97232-2045
US

IV. Provider business mailing address

650 NE HOLLADAY ST STE 1600
PORTLAND OR
97232-2035
US

V. Phone/Fax

Practice location:
  • Phone: 503-367-3630
  • Fax: 503-224-3126
Mailing address:
  • Phone: 503-367-3630
  • Fax: 503-224-3126

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberC4036
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateOR
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberC4036
License Number StateOR

VIII. Authorized Official

Name: DANIEL J GILBRIDE
Title or Position: DIRECTOR
Credential: MA, MRC, LPC
Phone: 503-367-3630