Healthcare Provider Details

I. General information

NPI: 1669092201
Provider Name (Legal Business Name): EXODUS RECOVERY SERVICES LLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/23/2020
Last Update Date: 09/01/2022
Certification Date: 09/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

230 N 3RD ST STE 105
HARRISBURG OR
97446-9679
US

IV. Provider business mailing address

230 N 3RD ST STE 105
HARRISBURG OR
97446-9679
US

V. Phone/Fax

Practice location:
  • Phone: 541-998-5660
  • Fax: 541-998-5678
Mailing address:
  • Phone: 541-998-5660
  • Fax: 541-998-5678

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ELIZABETH MERRITT
Title or Position: EXECUTIVE DIRECTOR
Credential: QMHP-R, CADCIII
Phone: 541-952-1719