MEDICARE: LUMIRA BEHAVIORAL HEALTH, 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	1041C0700X	Clinical Social Worker
2	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1487594198
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LUMIRA BEHAVIORAL HEALTH, LLC

Provider Business Mailing Address
First Line	:	1957 THOMPSON RD STE J
Second Line	:
City	:	COOS BAY
State	:	OR
Zip	:	97420-2040
Country	:	US
Telephone Number	:	518-791-2267
Fax Number	:

Provider Business Practice Location Address
First Line	:	1957 THOMPSON RD STE J
Second Line	:
City	:	COOS BAY
State	:	OR
Zip	:	97420-2040
Country	:	US
Telephone Number	:	518-791-2267
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	ADAM CLARK
Credential	:	LCSW
Telephone Number	:	518-791-2267

Provider Enumeration Date	:	03/31/2026
Last Update Date	:	03/31/2026

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