MEDICARE: SOUTH LANE MENTAL HEALTH SERVICES, INC

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	251S00000X	Community/Behavioral Health Agency

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1306905831
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTH LANE MENTAL HEALTH SERVICES, INC

Provider Business Mailing Address
First Line	:	PO BOX 5
Second Line	:
City	:	COTTAGE GROVE
State	:	OR
Zip	:	97424-0001
Country	:	US
Telephone Number	:	541-942-3939
Fax Number	:	541-942-9310

Provider Business Practice Location Address
First Line	:	1345 BIRCH AVE
Second Line	:
City	:	COTTAGE GROVE
State	:	OR
Zip	:	97424-1416
Country	:	US
Telephone Number	:	541-942-3939
Fax Number	:	541-942-9310

Authorized Official
Title or Position	:	ASSISTANT EXECUTIVE DIRECTOR
Name	:	ANDREW LEE YODER
Credential	:
Telephone Number	:	541-942-3939

Provider Enumeration Date	:	12/08/2006
Last Update Date	:	10/22/2024

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