Healthcare Provider Details

I. General information

NPI: 1851567655
Provider Name (Legal Business Name): LIBERTY MENTAL HEALTH CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/01/2008
Last Update Date: 05/01/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

145 WILSON ST S
SALEM OR
97302-4232
US

IV. Provider business mailing address

1247 COMMERCIAL ST SE
SALEM OR
97302-4203
US

V. Phone/Fax

Practice location:
  • Phone: 503-581-0463
  • Fax: 503-581-1669
Mailing address:
  • Phone: 503-581-0463
  • Fax: 503-581-1669

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberL3352-C1512
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: MS. LOREN S MELTZER
Title or Position: ADMINISTRATIVE DIRECTOR
Credential: JD,LPC,CADC
Phone: 503-302-4126