Provider Demographics
NPI:1699419606
Name:CARAVAN COUNSELING - PSYCHOTHERAPY, LLC
Entity type:Organization
Organization Name:CARAVAN COUNSELING - PSYCHOTHERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROFESSIONAL COUNSELOR ASSOCIATE
Authorized Official - Prefix:
Authorized Official - First Name:RIVER
Authorized Official - Middle Name:C
Authorized Official - Last Name:DELOGU-CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:CADC I
Authorized Official - Phone:503-383-1309
Mailing Address - Street 1:11720 SE ALDER ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97216-3868
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11720 SE ALDER ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97216-3868
Practice Address - Country:US
Practice Address - Phone:503-383-1309
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-25
Last Update Date:2024-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health