Healthcare Provider Details

I. General information

NPI: 1639256431
Provider Name (Legal Business Name): LINDA WITBECK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

913 GARDEN VALLEY BLVD BLDG 2, WARD 2, SARTP
ROSEBURG OR
97470
US

IV. Provider business mailing address

1281 MAGNOLIA DRIVE
ROSEBURG OR
97470
US

V. Phone/Fax

Practice location:
  • Phone: 541-440-1000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: