Healthcare Provider Details

I. General information

NPI: 1922912245
Provider Name (Legal Business Name): NEMORA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2026
Last Update Date: 10/02/2026
Certification Date: 10/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2801 PARK CENTER DR APT C603
ALEXANDRIA VA
22302-1431
US

IV. Provider business mailing address

5441 S MACADAM AVE STE R
PORTLAND OR
97239-3822
US

V. Phone/Fax

Practice location:
  • Phone: 703-472-2193
  • Fax:
Mailing address:
  • Phone: 703-472-2193
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL

VIII. Authorized Official

Name: GUIDO BLACUTT
Title or Position: OWNER
Credential:
Phone: 703-472-2193