Healthcare Provider Details

I. General information

NPI: 1295096907
Provider Name (Legal Business Name): MR. BRIAN TIMONTHY LONGWORTH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/30/2012
Last Update Date: 05/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1973 GARDEN AVE
EUGENE OR
97403-1934
US

IV. Provider business mailing address

2658 ATTICUS WAY
EUGENE OR
97404-4405
US

V. Phone/Fax

Practice location:
  • Phone: 541-606-5446
  • Fax:
Mailing address:
  • Phone: 541-606-5446
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
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:
Title or Position:
Credential:
Phone: