Provider Demographics
NPI:1003488420
Name:MORA SANTANA, JOSE ANTONIO (LPC)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:ANTONIO
Last Name:MORA SANTANA
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:355 S 34TH ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OR
Mailing Address - Zip Code:97478-6310
Mailing Address - Country:US
Mailing Address - Phone:541-515-2679
Mailing Address - Fax:
Practice Address - Street 1:66 CLUB RD STE 120
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-2439
Practice Address - Country:US
Practice Address - Phone:641-393-5983
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-14
Last Update Date:2021-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORR5467101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR5467OtherOHP
ORR5467Medicaid