Provider Demographics
NPI:1073060182
Name:SERENITY LANE
Entity Type:Organization
Organization Name:SERENITY LANE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM COORDINATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:HAYNES
Authorized Official - Suffix:
Authorized Official - Credentials:BS CADCII
Authorized Official - Phone:541-673-3504
Mailing Address - Street 1:2575 NW KLINE ST
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97471-8827
Mailing Address - Country:US
Mailing Address - Phone:541-673-3504
Mailing Address - Fax:541-673-4724
Practice Address - Street 1:2575 NW KLINE ST
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97471-8827
Practice Address - Country:US
Practice Address - Phone:541-673-3504
Practice Address - Fax:541-673-4724
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-07
Last Update Date:2016-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR13-12-59101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty