Healthcare Provider Details

I. General information

NPI: 1700549250
Provider Name (Legal Business Name): WELL AWARE THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/20/2021
Last Update Date: 10/20/2021
Certification Date: 10/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

132 E BROADWAY STE 323
EUGENE OR
97401-3154
US

IV. Provider business mailing address

132 E BROADWAY STE 323
EUGENE OR
97401-3154
US

V. Phone/Fax

Practice location:
  • Phone: 541-972-1145
  • Fax:
Mailing address:
  • Phone: 541-972-1145
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
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: KOLTEN KENNEDY
Title or Position: MANAGER
Credential: MA
Phone: 541-972-1145