=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952754038
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COUNSELING 360, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/13/2016
-----------------------------------------------------
Last Update Date | 07/13/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10700 SW BEAVERTON HILLSDALE HWY SUITE 450
-----------------------------------------------------
City | BEAVERTON
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97005-3019
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-928-6624
-----------------------------------------------------
Fax | 866-803-2248
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14588 SW SHOUE DR
-----------------------------------------------------
City | TIGARD
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97224-0913
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CLINICAL PSYCHOLOGIST
-----------------------------------------------------
Name | DR. MARY HACOPIAN
-----------------------------------------------------
Credential | PSY.D.
-----------------------------------------------------
Telephone | 503-928-6624
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 305S00000X
-----------------------------------------------------
Taxonomy Name | Point of Service
-----------------------------------------------------
License Number | 2430
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------