Healthcare Provider Details

I. General information

NPI: 1699593483
Provider Name (Legal Business Name): INTEGRATIVE MIND BODY PSYCHOTHERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/30/2024
Last Update Date: 09/30/2024
Certification Date: 09/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

818 SW FOREST AVE STE B
REDMOND OR
97756-2737
US

IV. Provider business mailing address

8114 SW POKEGAMA DR
POWELL BUTTE OR
97753-1564
US

V. Phone/Fax

Practice location:
  • Phone: 541-293-3039
  • Fax:
Mailing address:
  • Phone: 541-293-3039
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: AMANDA JUZA-HAMRICK
Title or Position: SOCIAL WORKER/ OWNER
Credential: LCSW
Phone: 541-293-3039