Organization
ETERNAL BLOSSOM COUNSELING LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
AIYANA LUCAS LCSW (LICENSED CLINICAL SOCIAL WORKER)
(971) 361-6747
Entity
Organization
Contact information
Practice address
4531 SE BELMONT ST STE 310, PORTLAND, OR 97215-1675
(503) 810-1170
Mailing address
3335 SE 69TH AVE, PORTLAND, OR 97206-2613
(503) 810-1170
Taxonomy
Speciality
Code
Description
License number
State
1041C0700X
Clinical Social Worker
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
500731868
—
OR
Enumeration date
04/08/2019
Last updated
04/08/2019
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