Healthcare Provider Details

I. General information

NPI: 1003488420
Provider Name (Legal Business Name): JOSE ANTONIO MORA SANTANA LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2021
Last Update Date: 07/14/2021
Certification Date: 07/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

66 CLUB RD STE 120
EUGENE OR
97401-2439
US

IV. Provider business mailing address

355 S 34TH ST
SPRINGFIELD OR
97478-6310
US

V. Phone/Fax

Practice location:
  • Phone: 641-393-5983
  • Fax:
Mailing address:
  • Phone: 541-515-2679
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberR5467
License Number StateOR

VII. Legacy identifiers

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

# 1
IdentifierR5467
Identifier TypeOTHER
Identifier StateOR
Identifier IssuerOHP
# 2
IdentifierR5467
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: