Basic Information
| Provider Information | |||||||||
| NPI: | 1396862074 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LUTHERAN COMMUNITY SERVICES NW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2036 LEROY ST | ||||||||
| Address2: | |||||||||
| City: | KLAMATH FALLS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 976011876 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5418833471 | ||||||||
| FaxNumber: | 5418833524 | ||||||||
| Practice Location | |||||||||
| Address1: | 2545 N ELDORADO AVE | ||||||||
| Address2: | |||||||||
| City: | KLAMATH FALLS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 976016423 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5418833471 | ||||||||
| FaxNumber: | 5418833524 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/26/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | PAGE | ||||||||
| AuthorizedOfficialFirstName: | HEIDI | ||||||||
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| AuthorizedOfficialTitleorPosition: | MENTAL HEALTH COUNSELOR | ||||||||
| AuthorizedOfficialTelephone: | 5418833471 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | PHD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC1900X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Counseling |
ID Information
| ID | Type | State | Issuer | Description | 090450 | 05 | OR | MEDICAID | 026825000 | 01 | OR | BCBS PROVIDER # | OTHER | 164285 | 05 | OR | MEDICAID |