Healthcare Provider Details

I. General information

NPI: 1174078356
Provider Name (Legal Business Name): CARE AND COUNSELING CENTER OF SOUTHERN OREGON, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/17/2016
Last Update Date: 04/25/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1322 E MCANDREWS RD STE 101
MEDFORD OR
97504-6177
US

IV. Provider business mailing address

1322 E MCANDREWS RD STE 101
MEDFORD OR
97504-6177
US

V. Phone/Fax

Practice location:
  • Phone: 541-779-4090
  • Fax: 541-770-8082
Mailing address:
  • Phone: 541-779-4090
  • Fax: 541-770-8082

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name: PATRICK ORMEROD
Title or Position: ADMINISTRATIVE DIRECTOR
Credential:
Phone: 541-779-4090