Healthcare Provider Details

I. General information

NPI: 1144193699
Provider Name (Legal Business Name): MINDHEALTH PSYCHIATRY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/29/2025
Last Update Date: 04/21/2026
Certification Date: 04/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 RATCLIFF DR SE STE 110
SALEM OR
97302-4576
US

IV. Provider business mailing address

710 E FOOTHILLS DR STE 104
NEWBERG OR
97132-6125
US

V. Phone/Fax

Practice location:
  • Phone: 541-224-8110
  • Fax: 800-783-8942
Mailing address:
  • Phone: 541-224-8110
  • Fax: 800-783-8942

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MRS. LAVENA MCCULLUM
Title or Position: OWNER
Credential: PMHNP-BC
Phone: 541-224-8110