Provider Demographics
NPI:1588297063
Name:POLLY GRAVELY COUNSELING LLC
Entity type:Organization
Organization Name:POLLY GRAVELY COUNSELING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROFESSIONAL COUNSELOR
Authorized Official - Prefix:
Authorized Official - First Name:POLLY
Authorized Official - Middle Name:
Authorized Official - Last Name:GRAVELY
Authorized Official - Suffix:
Authorized Official - Credentials:LPC, MFT
Authorized Official - Phone:503-310-7472
Mailing Address - Street 1:4028 SW 53RD PL
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97221-2015
Mailing Address - Country:US
Mailing Address - Phone:503-310-7472
Mailing Address - Fax:
Practice Address - Street 1:5319 SW WESTGATE DR STE 246
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97221-2434
Practice Address - Country:US
Practice Address - Phone:503-310-7472
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-12
Last Update Date:2021-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health