Healthcare Provider Details

I. General information

NPI: 1205707593
Provider Name (Legal Business Name): INLAND PSYCHIATRIC MEDICAL GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/17/2025
Last Update Date: 09/17/2025
Certification Date: 09/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1140 WILLAGILLESPIE RD STE 44
EUGENE OR
97401-6727
US

IV. Provider business mailing address

1140 WILLAGILLESPIE RD STE 44
EUGENE OR
97401-6727
US

V. Phone/Fax

Practice location:
  • Phone: 541-735-3241
  • Fax: 541-735-3455
Mailing address:
  • Phone: 541-735-3241
  • Fax: 541-735-3455

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VII. Legacy identifiers

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

# 1
Identifier1649217761
Identifier TypeMEDICAID
Identifier StateCA
Identifier Issuer

VIII. Authorized Official

Name: AMBER GUTIERREZ
Title or Position: ADMIN PROVIDER RELATIONS
Credential:
Phone: 909-289-4075