Healthcare Provider Details

I. General information

NPI: 1245757772
Provider Name (Legal Business Name): SOUTH LANE MENTAL HEALTH SERVICES, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/25/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1345 BIRCH AVE
COTTAGE GROVE OR
97424-1416
US

IV. Provider business mailing address

1345 BIRCH AVE
COTTAGE GROVE OR
97424-1416
US

V. Phone/Fax

Practice location:
  • Phone: 541-942-3939
  • Fax: 541-942-9310
Mailing address:
  • Phone: 541-942-3939
  • Fax: 541-942-9310

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number102491-83
License Number StateOR

VIII. Authorized Official

Name: MS. THERESE NADINE MASTIN
Title or Position: QUALITY MANAGEMENT DIRECTOR
Credential: MA
Phone: 541-767-4176