Healthcare Provider Details

I. General information

NPI: 1821276411
Provider Name (Legal Business Name): FIFTH AVENUE COUNSELING & CONSULTING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/05/2008
Last Update Date: 02/06/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1312 SW 16TH AVE #103
PORTLAND OR
97201-2516
US

IV. Provider business mailing address

1312 SW 16TH AVE #103
PORTLAND OR
97201-2516
US

V. Phone/Fax

Practice location:
  • Phone: 503-295-7974
  • Fax: 503-295-3727
Mailing address:
  • Phone: 503-295-7974
  • Fax: 503-295-3727

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberC1784
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberC2116
License Number StateOR
# 3
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberC0630
License Number StateOR

VIII. Authorized Official

Name: MR. PETER BARBUR
Title or Position: PRINCIPAL
Credential: LPC
Phone: 503-295-7974