MEDICARE: MINDHEALTH PSYCHIATRY LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0808X	Psychiatric/Mental Health Nurse Practitioner

General Provider Information

NPI Number	:	1144193699
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MINDHEALTH PSYCHIATRY LLC

Provider Business Mailing Address
First Line	:	710 E FOOTHILLS DR STE 104
Second Line	:
City	:	NEWBERG
State	:	OR
Zip	:	97132-6125
Country	:	US
Telephone Number	:	541-224-8110
Fax Number	:

Provider Business Practice Location Address
First Line	:	401 RATCLIFF DR SE STE 110
Second Line	:
City	:	SALEM
State	:	OR
Zip	:	97302-4576
Country	:	US
Telephone Number	:	541-224-8110
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MRS. LAVENA MCCULLUM
Credential	:	PMHNP-BC
Telephone Number	:	541-224-8110

Provider Enumeration Date	:	09/29/2025
Last Update Date	:	02/25/2026

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