=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629435441
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HEARTS MADE WHOLE COUNSELING, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/25/2016
-----------------------------------------------------
Last Update Date | 05/12/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12725 SW MILLIKAN WAY STE 300
-----------------------------------------------------
City | BEAVERTON
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97005-1687
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-906-7912
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12725 SW MILLIKAN WAY STE 300
-----------------------------------------------------
City | BEAVERTON
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97005-1687
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-906-7912
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LICENSED PROFESSIONAL COUNSELOR
-----------------------------------------------------
Name | MRS. USHIRIKA V. JOHNSON
-----------------------------------------------------
Credential | M.A
-----------------------------------------------------
Telephone | 503-906-7912
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | C3740
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------