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General NPI Number Information
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NPI Number | 1871069674
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Entity Type | Organization
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Legal Business Name | PORCHLIGHT CUSTOM COUNSELING LLC
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Dates
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Enumeration Date | 10/18/2018
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Last Update Date | 10/18/2018
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Provider Practice Location Address
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Address Line | 455 S KNOTT ST
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City | CANBY
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State | OR
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Zip | 97013-4426
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Country | US
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Telephone | 503-395-3301
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 344
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City | TURNER
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State | OR
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Zip | 97392-0344
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Country | US
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Telephone | 503-395-3301
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Fax |
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Authorized Official
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Title or Position | PART OWNER
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Name | MICA RICHARDS
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Credential | LMHC
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Telephone | 503-395-3301
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 103K00000X
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Taxonomy Name | Behavior Analyst
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State |
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