Healthcare Provider Details

I. General information

NPI: 1255251823
Provider Name (Legal Business Name): MENDING WATERS COUNSELING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/15/2026
Last Update Date: 07/15/2026
Certification Date: 07/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21850 HIGHWAY 62 # 200
SHADY COVE OR
97539-8715
US

IV. Provider business mailing address

PO BOX 1463
SHADY COVE OR
97539-1463
US

V. Phone/Fax

Practice location:
  • Phone: 541-241-2105
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name: RYAN PRICE
Title or Position: OWNER
Credential:
Phone: 541-241-2105