Provider Demographics
NPI:1124863261
Name:RADIANCE INTEGRATIVE HEALTH & WELLNESS
Entity type:Organization
Organization Name:RADIANCE INTEGRATIVE HEALTH & WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER, TREASURER
Authorized Official - Prefix:
Authorized Official - First Name:SUNDAURA
Authorized Official - Middle Name:
Authorized Official - Last Name:LITHMAN
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:541-973-3797
Mailing Address - Street 1:1130 SW MORRISON ST STE 328
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97205-2214
Mailing Address - Country:US
Mailing Address - Phone:503-743-8364
Mailing Address - Fax:
Practice Address - Street 1:8125 SE PINE ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97215-1554
Practice Address - Country:US
Practice Address - Phone:503-743-8364
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-06-29
Last Update Date:2024-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty