Provider Demographics
NPI:1174111561
Name:LIGHT MIND WELLNESS
Entity type:Organization
Organization Name:LIGHT MIND WELLNESS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:JULIA
Authorized Official - Middle Name:
Authorized Official - Last Name:PERRETTA
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:503-926-9567
Mailing Address - Street 1:5010 SE FOSTER RD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97206-3039
Mailing Address - Country:US
Mailing Address - Phone:503-926-9567
Mailing Address - Fax:
Practice Address - Street 1:6734 SE RAYMOND ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97206-4520
Practice Address - Country:US
Practice Address - Phone:503-926-9567
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-01
Last Update Date:2021-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1518377167OtherPERSONAL NPI