Healthcare Provider Details

I. General information

NPI: 1306456058
Provider Name (Legal Business Name): SOUTHERN OREGON CBT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/07/2020
Last Update Date: 10/29/2024
Certification Date: 10/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

235 W MAIN ST
JACKSONVILLE OR
97530-9278
US

IV. Provider business mailing address

PO BOX 4752
MEDFORD OR
97501-0197
US

V. Phone/Fax

Practice location:
  • Phone: 541-204-4933
  • Fax: 800-433-1396
Mailing address:
  • Phone: 541-500-8655
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State

VIII. Authorized Official

Name: KACY MULLEN
Title or Position: OWNER
Credential: PHD
Phone: 541-500-8655