Provider Demographics
NPI:1306315965
Name:PSYCHOLOGY & WELLNESS GROUP PDX LLC
Entity type:Organization
Organization Name:PSYCHOLOGY & WELLNESS GROUP PDX LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:SNOW
Authorized Official - Suffix:
Authorized Official - Credentials:MS, LPC
Authorized Official - Phone:503-345-3260
Mailing Address - Street 1:7555 SW HERMOSO WAY STE 120
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97223-8684
Mailing Address - Country:US
Mailing Address - Phone:503-345-3260
Mailing Address - Fax:503-345-3052
Practice Address - Street 1:7555 SW HERMOSO WAY STE 120
Practice Address - Street 2:
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97223-8684
Practice Address - Country:US
Practice Address - Phone:503-345-3260
Practice Address - Fax:503-345-3052
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-13
Last Update Date:2023-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500656380Medicaid