Mandala Mental and Behavioral Health, LLC

Primary specialty

Professional CounselorTaxonomy code 101YP2500X

License

C4036 Issued in OR

Legal business name

MANDALA MENTAL AND BEHAVIORAL HEALTH, LLC

Practice address

650 NE Holladay St Ste 16001614
Portland, OR 97232-2045

Phone

(503) 367-3630

Fax

(503) 224-3126

NPI assigned

Dec 29, 2017

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Daniel J Gilbride, MA, MRC, LPC

Title

Director

Phone

(503) 367-3630

Specialties & licenses 3

Addresses

Other identifiers 2

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1514505600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1529107200000",
    "number": "1104333103",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "650 NE HOLLADAY ST STE 1600",
            "city": "PORTLAND",
            "state": "OR",
            "postal_code": "972322035",
            "telephone_number": "503-367-3630",
            "fax_number": "503-224-3126"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "650 NE HOLLADAY ST STE 16001614",
            "city": "PORTLAND",
            "state": "OR",
            "postal_code": "972322045",
            "telephone_number": "503-367-3630",
            "fax_number": "503-224-3126"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "511 SW 10th Ave Ste 601",
            "address_purpose": "LOCATION",
            "city": "Portland",
            "state": "OR",
            "postal_code": "972052707",
            "country_code": "US",
            "telephone_number": "503-367-3630",
            "fax_number": "503-224-3126",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "address_1": "650 NE Holladay St Ste 16001614",
            "address_purpose": "LOCATION",
            "city": "Portland",
            "state": "OR",
            "postal_code": "972322045",
            "country_code": "US",
            "telephone_number": "503-367-3630",
            "fax_number": "503-224-3126",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "organization_name": "MANDALA MENTAL AND BEHAVIORAL HEALTH, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2017-12-29",
        "last_updated": "2018-06-16",
        "status": "A",
        "authorized_official_last_name": "GILBRIDE",
        "authorized_official_first_name": "DANIEL",
        "authorized_official_middle_name": "J",
        "authorized_official_title_or_position": "DIRECTOR",
        "authorized_official_telephone_number": "503-367-3630",
        "authorized_official_credential": "MA, MRC, LPC"
    },
    "taxonomies": [
        {
            "code": "101YP2500X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Counselor, Professional",
            "state": "OR",
            "license": "C4036",
            "primary": true
        },
        {
            "code": "1041C0700X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Social Worker, Clinical",
            "state": "OR",
            "license": null,
            "primary": false
        },
        {
            "code": "251S00000X",
            "taxonomy_group": "",
            "desc": "Community/Behavioral Health",
            "state": "OR",
            "license": "C4036",
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "NATIONAL PROVIDER NUMBER, TERESA CONLAN",
            "identifier": "13804154",
            "state": null
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "NATIONAL PROVIDER NUMBER, DANIEL GILBRIDE",
            "identifier": "1942662150",
            "state": null
        }
    ],
    "endpoints": [],
    "other_names": []
}

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• Professional Counselor in Portland, OR
• Providers in Portland, OR by specialty
• Professional Counselor in Oregon

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 16, 2018; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.