Basic Information
| Provider Information | |||||||||
| NPI: | 1992755664 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COUNTY OF LINCOLN | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | LINCOLN COUNTY HEALTH & HUMAN SERVICES | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 36 SW NYE ST | ||||||||
| Address2: | |||||||||
| City: | NEWPORT | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973653821 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412654179 | ||||||||
| FaxNumber: | 5415746252 | ||||||||
| Practice Location | |||||||||
| Address1: | 1010 SW COAST HWY | ||||||||
| Address2: | |||||||||
| City: | NEWPORT | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973655288 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412654947 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2006 | ||||||||
| LastUpdateDate: | 08/23/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WAGNER | ||||||||
| AuthorizedOfficialFirstName: | LESA | ||||||||
| AuthorizedOfficialMiddleName: | JEAN | ||||||||
| AuthorizedOfficialTitleorPosition: | INTERIM DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5412650445 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/18/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | N | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Case Manager/Care Coordinator | 2084P0800X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 261QM0855X | N | Ambulatory Health Care Facilities | Clinic/Center | Adolescent and Children Mental Health | 261QP0905X | N | Ambulatory Health Care Facilities | Clinic/Center | Public Health, State or Local | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 213144 | 05 | OR | MEDICAID | 165098 | 05 | OR | MEDICAID | 042957 | 05 | OR | MEDICAID |