Basic Information
| Provider Information | |||||||||
| NPI: | 1538180716 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LOOKING GLASS COMMUNITY SERVICES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1790 W 11TH AVE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | EUGENE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974023758 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5416862688 | ||||||||
| FaxNumber: | 5413457605 | ||||||||
| Practice Location | |||||||||
| Address1: | 260 E 11TH AVE | ||||||||
| Address2: | |||||||||
| City: | EUGENE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974013247 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5414844428 | ||||||||
| FaxNumber: | 5414847212 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/22/2006 | ||||||||
| LastUpdateDate: | 09/30/2016 | ||||||||
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| AuthorizedOfficialLastName: | JACKSON | ||||||||
| AuthorizedOfficialFirstName: | MARIE | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR OF FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 5416862688 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251V00000X | N | Agencies | Voluntary or Charitable | 101YA0400X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101Y00000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | 323P00000X | N | Residential Treatment Facilities | Psychiatric Residential Treatment Facility | 3245S0500X | N | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility | Substance Abuse Treatment, Children | 101YM0800X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 182421 | 05 | OR | MEDICAID | 183681 | 05 | OR | MEDICAID | 219972 | 05 | OR | MEDICAID |