Healthcare Provider Details

I. General information

NPI: 1255850889
Provider Name (Legal Business Name): PHILOMATH COUNSELING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/14/2017
Last Update Date: 09/14/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1229 MAIN ST. #105
PHILOMATH OR
97370
US

IV. Provider business mailing address

PO BOX 1606
PHILOMATH OR
97370-1606
US

V. Phone/Fax

Practice location:
  • Phone: 541-929-2878
  • Fax: 541-929-3770
Mailing address:
  • Phone: 541-929-2878
  • Fax: 541-929-3770

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberL4097
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier043278
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer

VIII. Authorized Official

Name: JEANNE A GREGG
Title or Position: MEMBER
Credential: LCSW
Phone: 541-929-2878