Healthcare Provider Details

I. General information

NPI: 1164159513
Provider Name (Legal Business Name): AUDREY CONNOR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2022
Last Update Date: 10/05/2026
Certification Date: 10/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2408 SW HALSEY ST BLDG H
TROUTDALE OR
97060-1020
US

IV. Provider business mailing address

COLUMBIA WELLNESS PO BOX 1847
LONGVIEW WA
98632
US

V. Phone/Fax

Practice location:
  • Phone: 503-262-4850
  • Fax:
Mailing address:
  • Phone: 360-353-9369
  • Fax: 360-577-0187

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberCG61597062
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code221700000X
TaxonomyArt Therapist
License Number
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: