Provider Demographics
NPI:1134991524
Name:MINDFUL THERAPY PDX PC
Entity type:Organization
Organization Name:MINDFUL THERAPY PDX PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:L
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:503-734-0552
Mailing Address - Street 1:636 N LOMBARD ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97217-1576
Mailing Address - Country:US
Mailing Address - Phone:503-734-0552
Mailing Address - Fax:
Practice Address - Street 1:423 NE 60TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-3725
Practice Address - Country:US
Practice Address - Phone:503-734-0552
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-27
Last Update Date:2023-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty