Basic Information
| Provider Information | |||||||||
| NPI: | 1447715834 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ARISE COUNSELING SERVICE LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2440 WILLAMETTE ST STE 201 | ||||||||
| Address2: | |||||||||
| City: | EUGENE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974053170 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413212278 | ||||||||
| FaxNumber: | 5412468826 | ||||||||
| Practice Location | |||||||||
| Address1: | 2440 WILLAMETTE ST STE 201 | ||||||||
| Address2: | |||||||||
| City: | EUGENE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974053170 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413212278 | ||||||||
| FaxNumber: | 5412468826 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/10/2019 | ||||||||
| LastUpdateDate: | 08/03/2020 | ||||||||
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| AuthorizedOfficialLastName: | KNOX | ||||||||
| AuthorizedOfficialFirstName: | HENRIETTA | ||||||||
| AuthorizedOfficialMiddleName: | WILHELMINA | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5413212278 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MA, LPC | ||||||||
| NPICertificationDate: | 08/03/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 500682607 | 05 | OR | MEDICAID |