Basic Information
| Provider Information | |||||||||
| NPI: | 1679850788 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NEVILLE | ||||||||
| FirstName: | CAROLYN | ||||||||
| MiddleName: | |||||||||
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| OtherOrganizationType: | |||||||||
| OtherLastName: | BROWN | ||||||||
| OtherFirstName: | CAROLYN | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 715 SW RAMSEY AVE | ||||||||
| Address2: | |||||||||
| City: | GRANTS PASS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975275500 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1175 EAST MAIN STREET | ||||||||
| Address2: | SUITE C1 | ||||||||
| City: | MEDFORD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417722209 | ||||||||
| FaxNumber: | 5417720966 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/03/2011 | ||||||||
| LastUpdateDate: | 11/02/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 175T00000X | Y |
No ID Information.