Basic Information
| Provider Information | |||||||||
| NPI: | 1093074882 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LUTHERAN COMMUNITY SERVICES NW | ||||||||
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| OtherOrganizationName: | LUTHERAN COMMUNITY SERVICES NW - BEND | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2545 N ELDORADO AVE | ||||||||
| Address2: | |||||||||
| City: | KLAMATH FALLS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 976016423 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5418833471 | ||||||||
| FaxNumber: | 5418833524 | ||||||||
| Practice Location | |||||||||
| Address1: | 2330 NE DIVISION ST STE 9B | ||||||||
| Address2: | |||||||||
| City: | BEND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977033530 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413235333 | ||||||||
| FaxNumber: | 5413235854 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/14/2012 | ||||||||
| LastUpdateDate: | 10/15/2019 | ||||||||
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| AuthorizedOfficialLastName: | JOHNSTON | ||||||||
| AuthorizedOfficialFirstName: | DANIEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | CONTRACT AND GRANT ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 2068163223 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | LUTHERAN COMMUNITY SERVICES NW | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 251S00000X | N | Agencies | Community/Behavioral Health | 305R00000X | N | Managed Care Organizations | Preferred Provider Organization | 101YM0800X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 1093074882 | 01 | OR | NPI NUMBER | OTHER | 283234 | 05 | OR | MEDICAID | 500674445 | 05 | OR | MEDICAID |