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General NPI Number Information
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NPI Number | 1154944536
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Entity Type | Organization
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Legal Business Name | FUNCTIONAL MENTAL HEALTH LLC
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Dates
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Enumeration Date | 05/20/2020
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Last Update Date | 01/27/2021
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Provider Practice Location Address
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Address Line | 11 SW BRANTLEY DR
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City | WINSTON
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State | OR
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Zip | 97496-4526
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Country | US
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Telephone | 541-679-0366
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Fax | 541-679-4821
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Provider Business Mailing Address
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Address Line | 11 SW BRANTLEY DR
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City | WINSTON
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State | OR
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Zip | 97496-4526
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Country | US
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Telephone | 541-679-0366
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Fax | 541-679-4821
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Authorized Official
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Title or Position | PMHNP
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Name | MCKENZIE SMITH
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Credential |
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Telephone | 541-326-8078
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number |
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License Number State |
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