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General NPI Number Information
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NPI Number | 1437925427
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Entity Type | Organization
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Legal Business Name | WISDOM WITHIN WELLNESS LLC
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Dates
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Enumeration Date | 11/30/2023
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Last Update Date | 12/04/2023
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Provider Practice Location Address
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Address Line | 1235 SE DIVISION ST STE 205
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City | PORTLAND
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State | OR
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Zip | 97202-1000
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Country | US
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Telephone | 503-473-2910
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Fax | 844-440-2129
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Provider Business Mailing Address
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Address Line | 3925 SE 62ND AVE
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City | PORTLAND
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State | OR
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Zip | 97206-3605
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Country | US
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Telephone | 503-473-2910
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Fax | 844-440-2129
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Authorized Official
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Title or Position | MEMBER MANAGER/PRESIDENT
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Name | KELLYJOY KANALEY
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Credential | LPC
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Telephone | 503-473-2910
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0850X
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Taxonomy Name | Adult Mental Health Clinic/Center
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License Number |
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License Number State |
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