Healthcare Provider Details

I. General information

NPI: 1346354446
Provider Name (Legal Business Name): UMPQUA COUNSELING PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/18/2006
Last Update Date: 08/23/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

770 SE KANE ST
ROSEBURG OR
97470-3943
US

IV. Provider business mailing address

770 SE KANE ST
ROSEBURG OR
97470-3943
US

V. Phone/Fax

Practice location:
  • Phone: 541-673-0057
  • Fax: 541-673-2270
Mailing address:
  • Phone: 541-673-0057
  • Fax: 541-673-2270

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateOR
# 3
Primary TaxonomyY
Taxonomy Code364SP0808X
TaxonomyPsychiatric/Mental Health Clinical Nurse Specialist
License Number
License Number StateOR

VIII. Authorized Official

Name: MR. KEN SERKOWNEK
Title or Position: OWNER
Credential: PH.D
Phone: 541-673-0057