Provider Demographics
NPI:1104401439
Name:UMPQUA FAMILY THERAPY LLC
Entity Type:Organization
Organization Name:UMPQUA FAMILY THERAPY LLC
Other - Org Name:MEREDITH CONCEPCION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MEREDITH
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:CONCEPCION
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:458-802-3883
Mailing Address - Street 1:1299 NW ELLAN ST STE 2
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97470-2031
Mailing Address - Country:US
Mailing Address - Phone:458-802-3883
Mailing Address - Fax:541-900-1840
Practice Address - Street 1:1299 NW ELLAN ST STE 2
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97470-2031
Practice Address - Country:US
Practice Address - Phone:458-802-3883
Practice Address - Fax:541-900-1840
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-17
Last Update Date:2021-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No251B00000XAgenciesCase Management
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR14105272Medicaid
ORL7566OtherLCSW LICENSE
OR1104401439OtherNPPES BUSINESS NPI
OR1265833388OtherNPI