Provider Demographics
NPI:1609192178
Name:LIFE GUIDE N.W., LLC
Entity type:Organization
Organization Name:LIFE GUIDE N.W., LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:STEVIE
Authorized Official - Middle Name:BRADFORD
Authorized Official - Last Name:HOGGANS
Authorized Official - Suffix:
Authorized Official - Credentials:MS, CACD III, QMHP
Authorized Official - Phone:503-255-2742
Mailing Address - Street 1:13232 SE STARK ST STE 3
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97233-1573
Mailing Address - Country:US
Mailing Address - Phone:503-255-2742
Mailing Address - Fax:503-255-2742
Practice Address - Street 1:13232 SE STARK ST STE 3
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97233-1573
Practice Address - Country:US
Practice Address - Phone:503-255-2742
Practice Address - Fax:503-255-2742
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-08
Last Update Date:2010-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty