Healthcare Provider Details

I. General information

NPI: 1922859198
Provider Name (Legal Business Name): EDGEWOOD MENTAL HEALTH AND WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/27/2024
Last Update Date: 01/12/2026
Certification Date: 01/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

280 LIBERTY ST SE STE 206
SALEM OR
97301-3554
US

IV. Provider business mailing address

24815 S ELLSWORTH RD APT 179
QUEEN CREEK AZ
85142-1929
US

V. Phone/Fax

Practice location:
  • Phone: 503-308-1301
  • Fax: 503-217-6526
Mailing address:
  • Phone: 503-308-1301
  • Fax: 503-217-6526

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code171W00000X
TaxonomyContractor
License Number
License Number State

VIII. Authorized Official

Name: EMMA LIME
Title or Position: OWNER
Credential:
Phone: 503-308-1301