=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225735905
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SIDEWALK BLOOMING, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/13/2023
-----------------------------------------------------
Last Update Date | 05/22/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5441 S MACADAM AVE STE N
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97239-6106
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-427-8135
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4207 SE WOODSTOCK BLVD # 241
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97206-6267
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | KATELIN WESTFALL
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 503-427-8135
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------