=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356850697
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ELEVATE WELLNESS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/28/2017
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6700 SW 105TH AVE STE 203
-----------------------------------------------------
City | BEAVERTON
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97008-8824
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-435-7663
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6700 SW 105TH AVE STE 203
-----------------------------------------------------
City | BEAVERTON
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97008-8824
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-435-7663
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | HEATHER DENISE GLENN
-----------------------------------------------------
Credential | LPC INTERN, NCC, CRC
-----------------------------------------------------
Telephone | 541-337-6381
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0850X
-----------------------------------------------------
Taxonomy Name | Adult Mental Health Clinic/Center
-----------------------------------------------------
License Number | R4844
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------