Healthcare Provider Details

I. General information

NPI: 1134834567
Provider Name (Legal Business Name): BLACK SHEEP THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/19/2023
Last Update Date: 12/23/2024
Certification Date: 12/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1257 HIGH ST
EUGENE OR
97401-3282
US

IV. Provider business mailing address

3425 POTTER ST
EUGENE OR
97405-4268
US

V. Phone/Fax

Practice location:
  • Phone: 541-329-9470
  • Fax:
Mailing address:
  • Phone: 541-329-9470
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: JINXI CADDEL
Title or Position: OWNER
Credential: LPC
Phone: 541-329-9470