Healthcare Provider Details

I. General information

NPI: 1073367256
Provider Name (Legal Business Name): OCTAVE BEHAVIORAL MICHIGAN PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/15/2024
Last Update Date: 04/15/2024
Certification Date: 04/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1127 BROADWAY ST NE STE 310
SALEM OR
97301-1143
US

IV. Provider business mailing address

625 MARKET ST FL 15
SAN FRANCISCO CA
94105-3316
US

V. Phone/Fax

Practice location:
  • Phone: 415-360-3833
  • Fax: 628-234-3048
Mailing address:
  • Phone: 650-504-2289
  • Fax: 628-234-3048

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State

VIII. Authorized Official

Name: KYM EVERETT
Title or Position: VP, REVENUE OPERATIONS
Credential:
Phone: 650-504-2289