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General NPI Number Information
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NPI Number | 1578958534
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Entity Type | Organization
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Legal Business Name | MODERN MINDFUL PSYCHOTHERAPY
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Dates
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Enumeration Date | 04/06/2015
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Last Update Date | 04/06/2015
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Provider Practice Location Address
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Address Line | 2325 E BURNSIDE ST #201
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City | PORTLAND
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State | OR
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Zip | 97214-1655
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Country | US
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Telephone | 503-564-8289
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Fax |
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Provider Business Mailing Address
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Address Line | 2325 E BURNSIDE ST #201
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City | PORTLAND
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State | OR
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Zip | 97214-1655
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Country | US
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Telephone | 503-564-8289
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Fax |
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Authorized Official
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Title or Position | FOUNDER
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Name | AMELIA MORGAN-ROTHSCHILD
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Credential | M.A., L.P.C
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Telephone | 503-564-8289
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | C3644
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License Number State | OR
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