MEDICARE: OUR INNER LANDSCAPE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	C4280	OR

General Provider Information

NPI Number	:	1346792231
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OUR INNER LANDSCAPE

Provider Business Mailing Address
First Line	:	2305 SE 50TH AVE
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97215-3853
Country	:	US
Telephone Number	:	503-729-5790
Fax Number	:

Provider Business Practice Location Address
First Line	:	4333 SE 35TH AVE
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97202-3317
Country	:	US
Telephone Number	:	503-729-5790
Fax Number	:

Authorized Official
Title or Position	:	CLINICAL MENTAL HEALTH COUNSELOR
Name	:	IVY KATZ
Credential	:	LPC
Telephone Number	:	503-729-5790

Provider Enumeration Date	:	10/26/2016
Last Update Date	:	10/26/2016

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Directions to “OUR INNER LANDSCAPE ” Practice Location

Language	Start Address	Practice Location

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