Healthcare Provider Details

I. General information

NPI: 1538665013
Provider Name (Legal Business Name): ROSEBURG THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/03/2018
Last Update Date: 04/13/2026
Certification Date: 04/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2460 NW TROOST ST
ROSEBURG OR
97471-7704
US

IV. Provider business mailing address

2460 NW TROOST ST
ROSEBURG OR
97471-7704
US

V. Phone/Fax

Practice location:
  • Phone: 541-900-4285
  • Fax: 888-810-2993
Mailing address:
  • Phone: 541-900-4285
  • Fax: 888-810-2993

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 Code1041C0700X
TaxonomyClinical Social Worker
License NumberL7631
License Number StateOR

VIII. Authorized Official

Name: ROBERT JOSH LYDON
Title or Position: OWNER/OPERATOR
Credential: LCSW L7631
Phone: 541-620-0425