Healthcare Provider Details

I. General information

NPI: 1558721340
Provider Name (Legal Business Name): OCTARINE THERAPEUTIC MENTAL HEALTH SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/07/2016
Last Update Date: 03/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

492 E 13TH AVE 209
EUGENE OR
97401-4268
US

IV. Provider business mailing address

492 E 13TH AVE 209
EUGENE OR
97401-4268
US

V. Phone/Fax

Practice location:
  • Phone: 458-205-5725
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateOR

VII. Legacy identifiers

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

# 1
Identifier1508254517
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer

VIII. Authorized Official

Name: JACQUELINE HALL
Title or Position: PMHNP
Credential:
Phone: 458-205-5725