Provider Demographics
NPI:1437997145
Name:PACIFIC NW MINDFUL CHANGE LLC
Entity type:Organization
Organization Name:PACIFIC NW MINDFUL CHANGE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:RETTON
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:503-329-8965
Mailing Address - Street 1:1234 KERNS AVE SW
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24015-2537
Mailing Address - Country:US
Mailing Address - Phone:503-329-8965
Mailing Address - Fax:
Practice Address - Street 1:304 MARKET ST SE UNIT E
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24011-2102
Practice Address - Country:US
Practice Address - Phone:540-824-4461
Practice Address - Fax:503-400-7452
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-17
Last Update Date:2024-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty