Basic Information
| Provider Information | |||||||||
| NPI: | 1538665013 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ROSEBURG THERAPY LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 272 NW MEDICAL LOOP STE E | ||||||||
| Address2: | |||||||||
| City: | ROSEBURG | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974715545 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5419004285 | ||||||||
| FaxNumber: | 8888102993 | ||||||||
| Practice Location | |||||||||
| Address1: | 272 NW MEDICAL LOOP STE E | ||||||||
| Address2: | |||||||||
| City: | ROSEBURG | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974715545 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5419004285 | ||||||||
| FaxNumber: | 8888102993 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/03/2018 | ||||||||
| LastUpdateDate: | 09/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | LYDON | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | JOSH | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/OPERATOR | ||||||||
| AuthorizedOfficialTelephone: | 5419004285 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | LCSW L7631 | ||||||||
| NPICertificationDate: | 09/22/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | L7631 | OR | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical | 101YM0800X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 500743892 | 05 | OR | MEDICAID |