=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184984056
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COUNSELING NW LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/24/2012
-----------------------------------------------------
Last Update Date | 01/04/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1525 NE WEIDLER ST SUITE 201
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97232-1410
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-277-9003
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1525 NE WEIDLER ST SUITE 201
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97232-1410
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-277-9003
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SOCIAL WORKER
-----------------------------------------------------
Name | MS. VERDA DEW
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 503-277-9003
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | L5343
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------