Basic Information
| Provider Information | |||||||||
| NPI: | 1720105489 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LUTHERAN COMMUNITY SERVICES NORTHWEST | ||||||||
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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: | 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: | 08/10/2021 | ||||||||
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| AuthorizedOfficialLastName: | CLARK | ||||||||
| AuthorizedOfficialFirstName: | SHELIA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING | ||||||||
| AuthorizedOfficialTelephone: | 5412013973 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 08/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health | 261QM0801X | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | 090450 | 05 | OR | MEDICAID | 026825000 | 01 | OR | BCBS PROVIDER # | OTHER |