=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649304338
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MINDFUL MEDICINE, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/15/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8283 SW BARBUR BLVD
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97219-2871
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-245-4524
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4110 SE HAWTHORNE BLVD # 249
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97214-5246
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-245-4524
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PSYCHIATRIST
-----------------------------------------------------
Name | DR. DANIEL JAMES ENGLE
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 503-245-4524
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | MD24819
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------