NPIMap

Organization Active NPI

Eternal Blossom Counseling LLC

  • Clinical Social Worker
  • Portland, OR
National Provider Identifier
1104389170
Registry record updated Apr 8, 2019
On this page

Key facts

NPPES NPI Registry
Primary specialty
Clinical Social WorkerTaxonomy code 1041C0700X
Legal business name
ETERNAL BLOSSOM COUNSELING LLC
Practice address
4531 SE Belmont St Ste 310
Portland, OR 97215-1675
Phone
(503) 810-1170
NPI assigned
Apr 8, 2019
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Apr 8, 2019

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

Authorized official

Name
Aiyana Lucas, LCSWNPI 1205282514
Title
Licensed Clinical Social Worker
Phone
(971) 361-6747

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Clinical Social WorkerGroup: 193400000X SINGLE SPECIALTY GROUP 1041C0700X Primary

Addresses

Primary practice location

4531 SE Belmont St Ste 310
Portland, OR 97215-1675

Mailing address

3335 SE 69TH Ave
Portland, OR 97206-2613
Phone (503) 810-1170

Other identifiers 1

IdentifierTypeStateIssuer
500731868MedicaidOR

National Provider Directory

National Provider Directory

Practitioners & affiliated clinicians

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

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

{
    "created_epoch": "1554681600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1554681600000",
    "number": "1104389170",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3335 SE 69TH AVE",
            "city": "PORTLAND",
            "state": "OR",
            "postal_code": "972062613",
            "telephone_number": "503-810-1170"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4531 SE BELMONT ST STE 310",
            "city": "PORTLAND",
            "state": "OR",
            "postal_code": "972151675",
            "telephone_number": "503-810-1170"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "ETERNAL BLOSSOM COUNSELING LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2019-04-08",
        "last_updated": "2019-04-08",
        "status": "A",
        "authorized_official_last_name": "LUCAS",
        "authorized_official_first_name": "AIYANA",
        "authorized_official_title_or_position": "LICENSED CLINICAL SOCIAL WORKER",
        "authorized_official_telephone_number": "971-361-6747",
        "authorized_official_credential": "LCSW"
    },
    "taxonomies": [
        {
            "code": "1041C0700X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Social Worker, Clinical",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "500731868",
            "state": "OR"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Portland, OR

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 8, 2019; 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.