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General NPI Number Information
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NPI Number | 1104333103
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Entity Type | Organization
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Legal Business Name | MANDALA MENTAL AND BEHAVIORAL HEALTH, LLC
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Dates
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Enumeration Date | 12/29/2017
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Last Update Date | 06/16/2018
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Provider Practice Location Address
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Address Line | 650 NE HOLLADAY ST STE 16001614
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City | PORTLAND
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State | OR
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Zip | 97232-2045
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Country | US
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Telephone | 503-367-3630
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Fax | 503-224-3126
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Provider Business Mailing Address
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Address Line | 650 NE HOLLADAY ST STE 1600
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City | PORTLAND
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State | OR
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Zip | 97232-2035
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Country | US
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Telephone | 503-367-3630
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Fax | 503-224-3126
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Authorized Official
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Title or Position | DIRECTOR
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Name | DANIEL J GILBRIDE
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Credential | MA, MRC, LPC
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Telephone | 503-367-3630
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number |
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License Number State | OR
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Taxonomy #2
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | C4036
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License Number State | OR
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Taxonomy #3
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | C4036
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License Number State | OR
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