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General NPI Number Information
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NPI Number | 1538793591
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Entity Type | Organization
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Legal Business Name | HEADWATERS THERAPY LLC
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Dates
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Enumeration Date | 02/28/2020
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Last Update Date | 06/25/2020
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Provider Practice Location Address
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Address Line | 927 COUNTRY CLUB RD STE 200
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City | EUGENE
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State | OR
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Zip | 97401-2272
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Country | US
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Telephone | 541-604-8822
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Fax | 541-359-1134
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Provider Business Mailing Address
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Address Line | 927 COUNTRY CLUB RD STE 200
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City | EUGENE
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State | OR
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Zip | 97401-2272
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Country | US
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Telephone | 541-604-8822
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Fax | 541-359-1134
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Authorized Official
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Title or Position | LICENSED MARRIAGE & FAMILY THERAPIS
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Name | MR. RYAN S SMITH
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Credential | M.ED, LMFT
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Telephone | 541-868-2004
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number |
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License Number State |
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