Provider Demographics
NPI:1902128804
Name:BASIC MINDFULNESS PORTLAND, LLC
Entity Type:Organization
Organization Name:BASIC MINDFULNESS PORTLAND, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JANET
Authorized Official - Middle Name:M
Authorized Official - Last Name:SIMS
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:503-719-5499
Mailing Address - Street 1:1920 NW JOHNSON ST
Mailing Address - Street 2:SUITE 103
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97209-1325
Mailing Address - Country:US
Mailing Address - Phone:503-719-5499
Mailing Address - Fax:
Practice Address - Street 1:1920 NW JOHNSON ST
Practice Address - Street 2:SUITE 103
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97209-1325
Practice Address - Country:US
Practice Address - Phone:503-719-5499
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-18
Last Update Date:2010-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1978103TC0700X
OR42201041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty