Provider Demographics
NPI:1588411060
Name:FLOURISH AUTHENTICALLY LLC
Entity type:Organization
Organization Name:FLOURISH AUTHENTICALLY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER AND PSYCHOTHERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:LILY
Authorized Official - Middle Name:S
Authorized Official - Last Name:KRUTEL
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:510-626-0215
Mailing Address - Street 1:833 SE MAIN ST.
Mailing Address - Street 2:BOX 302
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214
Mailing Address - Country:US
Mailing Address - Phone:510-626-0215
Mailing Address - Fax:
Practice Address - Street 1:833 SE MAIN ST # 213
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214-3454
Practice Address - Country:US
Practice Address - Phone:510-626-0215
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-05-02
Last Update Date:2024-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty