Healthcare Provider Details

I. General information

NPI: 1316856594
Provider Name (Legal Business Name): CENTER FOR COUNSELING AND THERAPEUTIC WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/03/2026
Last Update Date: 09/03/2026
Certification Date: 09/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5441 S MACADAM AVE STE R
PORTLAND OR
97239-3822
US

IV. Provider business mailing address

5441 S MACADAM AVE STE R
PORTLAND OR
97239-3822
US

V. Phone/Fax

Practice location:
  • Phone: 985-224-3497
  • Fax:
Mailing address:
  • Phone: 985-224-3497
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: NOHA MOSTAFA MOSTAFA BALBOUL
Title or Position: FOUNDER
Credential: LPC, MS, NCC
Phone: 985-224-3497