Agate Moon Ecotherapy Collective, Licensed Clinical Social Worker, Inc

Primary specialty

Mental Health Clinic/Center (Including Community Mental Health Center)Taxonomy code 261QM0801X

Legal business name

AGATE MOON ECOTHERAPY COLLECTIVE, LICENSED CLINICAL SOCIAL WORKER, INC

Practice address

1776 Market Ave
McKinleyville, CA 95519-4209

Phone

(503) 440-5924

NPI assigned

May 9, 2023

Organization subpart

No

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

Authorized official

Name

Mr. Bo Jason Hamer, LCSW

Title

Ceo - Clinical Director

Phone

(503) 440-5924

Specialties & licenses 2

Addresses

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

{
    "created_epoch": "1683590400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1683676800000",
    "number": "1407546989",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1776 MARKET AVE",
            "city": "MCKINLEYVILLE",
            "state": "CA",
            "postal_code": "955194209"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1776 MARKET AVE",
            "city": "MCKINLEYVILLE",
            "state": "CA",
            "postal_code": "955194209",
            "telephone_number": "503-440-5924"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "AGATE MOON ECOTHERAPY COLLECTIVE, LICENSED CLINICAL SOCIAL WORKER, INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2023-05-09",
        "last_updated": "2023-05-10",
        "certification_date": "2023-05-10",
        "status": "A",
        "authorized_official_last_name": "HAMER",
        "authorized_official_first_name": "BO",
        "authorized_official_middle_name": "JASON",
        "authorized_official_title_or_position": "CEO - CLINICAL DIRECTOR",
        "authorized_official_telephone_number": "503-440-5924",
        "authorized_official_name_prefix": "Mr.",
        "authorized_official_credential": "LCSW"
    },
    "taxonomies": [
        {
            "code": "261QM0801X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Mental Health (Including Community Mental Health Center)",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "261QM0855X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Adolescent and Children Mental Health",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Isaiah Carter Akselsen

• Mental Health Clinic/Center (Including Community Mental Health Center) in McKinleyville, CA
• Providers in McKinleyville, CA by specialty
• Mental Health Clinic/Center (Including Community Mental Health Center) in California

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 10, 2023; 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.