Healthcare Provider Details

I. General information

NPI: 1538180716
Provider Name (Legal Business Name): LOOKING GLASS COMMUNITY SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2006
Last Update Date: 09/30/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

260 E 11TH AVE
EUGENE OR
97401-3247
US

IV. Provider business mailing address

1790 W 11TH AVE SUITE 200
EUGENE OR
97402-3758
US

V. Phone/Fax

Practice location:
  • Phone: 541-484-4428
  • Fax: 541-484-7212
Mailing address:
  • Phone: 541-686-2688
  • Fax: 541-345-7605

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251V00000X
TaxonomyVoluntary or Charitable Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code323P00000X
TaxonomyPsychiatric Residential Treatment Facility
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code3245S0500X
TaxonomyChildren's Substance Abuse Rehabilitation Facility
License Number
License Number State
# 6
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:

# 1
Identifier182421
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer
# 2
Identifier183681
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer
# 3
Identifier219972
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer

VIII. Authorized Official

Name: MS. MARIE JACKSON
Title or Position: DIRECTOR OF FINANCE
Credential:
Phone: 541-686-2688