Provider Demographics
NPI:1124851167
Name:A LITTLE LIGHT THERAPY COLLECTIVE
Entity type:Organization
Organization Name:A LITTLE LIGHT THERAPY COLLECTIVE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:JORDAN
Authorized Official - Middle Name:MAE
Authorized Official - Last Name:DOBROVOLNY
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:503-994-6702
Mailing Address - Street 1:4605 NE FREMONT ST STE 210F
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97213-1707
Mailing Address - Country:US
Mailing Address - Phone:503-994-6702
Mailing Address - Fax:
Practice Address - Street 1:4605 NE FREMONT ST STE 210F
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-1707
Practice Address - Country:US
Practice Address - Phone:503-994-6702
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-08-23
Last Update Date:2024-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty