Basic Information
| Provider Information | |||||||||
| NPI: | 1932741550 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LUTHERAN COMMUNITY SERVICES NW | ||||||||
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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: | 1199 B AVE | ||||||||
| Address2: | |||||||||
| City: | TERREBONNE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977609440 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5415043829 | ||||||||
| FaxNumber: | 5415485889 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/15/2019 | ||||||||
| LastUpdateDate: | 10/15/2019 | ||||||||
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| AuthorizedOfficialLastName: | JOHNSTON | ||||||||
| AuthorizedOfficialFirstName: | DANIEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | CONTRACT AND GRANT ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 2068163223 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | LUTHERAN COMMUNITY SERVICES NW | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 251S00000X | N | Agencies | Community/Behavioral Health | 101YM0800X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.