MEDICARE: DRIFTLINE COUNSELING LLC

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

General Provider Information

NPI Number	:	1619794633
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DRIFTLINE COUNSELING LLC

Provider Business Mailing Address
First Line	:	80 SE MADISON ST STE 242
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97214-4527
Country	:	US
Telephone Number	:	503-208-6009
Fax Number	:

Provider Business Practice Location Address
First Line	:	80 SE MADISON ST STE 242
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97214-4527
Country	:	US
Telephone Number	:	503-208-6009
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	ERIKA TARJAN
Credential	:	LMFT, CADC1
Telephone Number	:	503-208-6009

Provider Enumeration Date	:	09/21/2024
Last Update Date	:	09/21/2024

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