Provider Demographics
NPI:1093074882
Name:LUTHERAN COMMUNITY SERVICES NW
Entity Type:Organization
Organization Name:LUTHERAN COMMUNITY SERVICES NW
Other - Org Name:LUTHERAN COMMUNITY SERVICES NW - BEND
Other - Org Type:Other Name
Authorized Official - Title/Position:CONTRACT AND GRANT ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:206-816-3223
Mailing Address - Street 1:2545 N ELDORADO AVE
Mailing Address - Street 2:
Mailing Address - City:KLAMATH FALLS
Mailing Address - State:OR
Mailing Address - Zip Code:97601-6423
Mailing Address - Country:US
Mailing Address - Phone:541-883-3471
Mailing Address - Fax:541-883-3524
Practice Address - Street 1:2330 NE DIVISION ST STE 9B
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97703-3530
Practice Address - Country:US
Practice Address - Phone:541-323-5333
Practice Address - Fax:541-323-5854
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LUTHERAN COMMUNITY SERVICES NW
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-05-14
Last Update Date:2019-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral Health
No305R00000XManaged Care OrganizationsPreferred Provider OrganizationGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1093074882OtherNPI NUMBER
OR283234Medicaid
OR500674445Medicaid