Provider Demographics
NPI:1003059296
Name:MASTIN, THERESE N (MA, QMHP)
Entity Type:Individual
Prefix:
First Name:THERESE
Middle Name:N
Last Name:MASTIN
Suffix:
Gender:F
Credentials:MA, QMHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 N 9TH ST
Mailing Address - Street 2:PO BOX 5
Mailing Address - City:COTTAGE GROVE
Mailing Address - State:OR
Mailing Address - Zip Code:97424-1307
Mailing Address - Country:US
Mailing Address - Phone:541-942-2850
Mailing Address - Fax:541-942-1574
Practice Address - Street 1:1345 BIRCH AVE
Practice Address - Street 2:
Practice Address - City:COTTAGE GROVE
Practice Address - State:OR
Practice Address - Zip Code:97424-1416
Practice Address - Country:US
Practice Address - Phone:541-942-3939
Practice Address - Fax:541-942-9310
Is Sole Proprietor?:No
Enumeration Date:2009-04-17
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR019047Medicaid