Healthcare Provider Details

I. General information

NPI: 1609731835
Provider Name (Legal Business Name): IMAGINATIVE HEALING COLLECTIVE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2025
Last Update Date: 12/19/2025
Certification Date: 12/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28925 SW BOBERG RD
WILSONVILLE OR
97070-8218
US

IV. Provider business mailing address

29385 SW TETON WAY
WILSONVILLE OR
97070-8501
US

V. Phone/Fax

Practice location:
  • Phone: 503-939-9447
  • Fax:
Mailing address:
  • Phone: 503-939-9447
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: CARMEN RYAN
Title or Position: OWNER/COUNSELOR
Credential: LPC, MS, MBA
Phone: 503-939-9447