=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528983087
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SPIRAL TIDE THERAPY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/12/2026
-----------------------------------------------------
Last Update Date | 08/14/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5134 SW CUSTER ST
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97219-1482
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-961-0203
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 19192
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97280-0192
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-961-0203
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | KELSEY ANNE LANGILLE
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 360-961-0203
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------