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General NPI Number Information
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NPI Number | 1306456058
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Entity Type | Organization
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Legal Business Name | SOUTHERN OREGON CBT LLC
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Dates
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Enumeration Date | 08/07/2020
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Last Update Date | 10/29/2024
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Provider Practice Location Address
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Address Line | 235 W MAIN ST
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City | JACKSONVILLE
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State | OR
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Zip | 97530-9278
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Country | US
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Telephone | 541-204-4933
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Fax | 800-433-1396
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Provider Business Mailing Address
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Address Line | PO BOX 4752
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City | MEDFORD
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State | OR
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Zip | 97501-0197
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Country | US
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Telephone | 541-500-8655
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | KACY MULLEN
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Credential | PHD
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Telephone | 541-500-8655
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number |
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License Number State |
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