Healthcare Provider Details

I. General information

NPI: 1538793591
Provider Name (Legal Business Name): HEADWATERS THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/28/2020
Last Update Date: 06/25/2020
Certification Date: 06/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

927 COUNTRY CLUB RD STE 200
EUGENE OR
97401-2272
US

IV. Provider business mailing address

927 COUNTRY CLUB RD STE 200
EUGENE OR
97401-2272
US

V. Phone/Fax

Practice location:
  • Phone: 541-604-8822
  • Fax: 541-359-1134
Mailing address:
  • Phone: 541-604-8822
  • Fax: 541-359-1134

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name: MR. RYAN S SMITH
Title or Position: LICENSED MARRIAGE & FAMILY THERAPIS
Credential: M.ED, LMFT
Phone: 541-868-2004