Provider Demographics
NPI:1245757772
Name:SOUTH LANE MENTAL HEALTH SERVICES, INC
Entity Type:Organization
Organization Name:SOUTH LANE MENTAL HEALTH SERVICES, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:QUALITY MANAGEMENT DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:THERESE
Authorized Official - Middle Name:NADINE
Authorized Official - Last Name:MASTIN
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:541-767-4176
Mailing Address - Street 1:1345 BIRCH AVE
Mailing Address - Street 2:
Mailing Address - City:COTTAGE GROVE
Mailing Address - State:OR
Mailing Address - Zip Code:97424-1416
Mailing Address - Country:US
Mailing Address - Phone:541-942-3939
Mailing Address - Fax:541-942-9310
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-25
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR102491-83261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder