Healthcare Provider Details

I. General information

NPI: 1891272324
Provider Name (Legal Business Name): CRESSALL PSYCHIATRIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/26/2018
Last Update Date: 07/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

240 E 12TH AVE
EUGENE OR
97401-3245
US

IV. Provider business mailing address

PO BOX 42283
EUGENE OR
97404-0600
US

V. Phone/Fax

Practice location:
  • Phone: 541-232-3131
  • Fax: 541-357-9952
Mailing address:
  • Phone: 541-232-3131
  • Fax: 541-357-9952

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number201500826NP-PP
License Number StateOR

VIII. Authorized Official

Name: CASSANDRE CRESSALL
Title or Position: OWNER
Credential: PMHNP-BC
Phone: 541-232-3131