Healthcare Provider Details

I. General information

NPI: 1265833388
Provider Name (Legal Business Name): MEREDITH ANN CONCEPCION LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/08/2014
Last Update Date: 05/13/2023
Certification Date: 05/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1299 NW ELLAN ST STE 2
ROSEBURG OR
97470-2031
US

IV. Provider business mailing address

1299 NW ELLAN ST STE 2
ROSEBURG OR
97470-2031
US

V. Phone/Fax

Practice location:
  • Phone: 458-802-3883
  • Fax: 541-900-1840
Mailing address:
  • Phone: 458-802-3883
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberL7566
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number36490
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberL7566
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: