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General NPI Number Information
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NPI Number | 1124851167
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Entity Type | Organization
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Legal Business Name | A LITTLE LIGHT COLLECTIVE, LLC
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Dates
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Enumeration Date | 08/23/2024
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Last Update Date | 06/03/2025
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Provider Practice Location Address
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Address Line | 4605 NE FREMONT ST STE 210F
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City | PORTLAND
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State | OR
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Zip | 97213-1707
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Country | US
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Telephone | 503-994-6702
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Fax |
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Provider Business Mailing Address
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Address Line | 1717 NE 42ND AVE STE 3200
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City | PORTLAND
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State | OR
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Zip | 97213-1572
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Country | US
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Telephone | 503-994-6702
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Fax |
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Authorized Official
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Title or Position | MEMBER
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Name | JORDAN MAE DOBROVOLNY
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Credential | LCSW
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Telephone | 503-994-6702
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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 |
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Taxonomy #2
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number |
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License Number State |
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