Healthcare Provider Details

I. General information

NPI: 1770254690
Provider Name (Legal Business Name): COLLECTIVE ELEMENTS PSYCHOTHERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/21/2021
Last Update Date: 09/21/2021
Certification Date: 09/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

777 HIGH ST STE 240
EUGENE OR
97401-2759
US

IV. Provider business mailing address

777 HIGH ST STE 240
EUGENE OR
97401-2759
US

V. Phone/Fax

Practice location:
  • Phone: 541-712-3011
  • Fax:
Mailing address:
  • Phone:
  • 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: WILLIAM DUSENBERRY
Title or Position: LICENSED PROFESSIONAL COUNSELOR
Credential:
Phone: 541-222-9596