Healthcare Provider Details

I. General information

NPI: 1275123762
Provider Name (Legal Business Name): SPECTRUM COUNSELING AND MENTAL WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/19/2021
Last Update Date: 01/08/2024
Certification Date: 01/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1220 SW MORRISON ST STE 1201
PORTLAND OR
97205-2231
US

IV. Provider business mailing address

101 SW MADISON ST UNIT 9152
PORTLAND OR
97204-3264
US

V. Phone/Fax

Practice location:
  • Phone: 971-373-4497
  • Fax:
Mailing address:
  • Phone: 971-373-4497
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name: LILYAN SMITH-MOORE
Title or Position: CHAIR
Credential:
Phone: 971-373-4497