Basic Information
| Provider Information | |||||||||
| NPI: | 1811278062 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BATES | ||||||||
| FirstName: | MISTY | ||||||||
| MiddleName: | ROSE | ||||||||
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| Credential: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2145 CENTENNIAL PLZ | ||||||||
| Address2: | |||||||||
| City: | EUGENE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974012474 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5414856340 | ||||||||
| FaxNumber: | 5419843124 | ||||||||
| Practice Location | |||||||||
| Address1: | 2145 CENTENNIAL PLZ | ||||||||
| Address2: | |||||||||
| City: | EUGENE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5414856340 | ||||||||
| FaxNumber: | 5419843124 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/01/2011 | ||||||||
| LastUpdateDate: | 08/07/2019 | ||||||||
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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 | 171M00000X | N | Other Service Providers | Case Manager/Care Coordinator | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 123190 | 05 | OR | MEDICAID |