Provider Demographics
NPI:1346354446
Name:UMPQUA COUNSELING PC
Entity Type:Organization
Organization Name:UMPQUA COUNSELING PC
Other - Org Name:UMPQUA COUNSELING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:KEN
Authorized Official - Middle Name:
Authorized Official - Last Name:SERKOWNEK
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:541-673-0057
Mailing Address - Street 1:770 SE KANE ST
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97470-3943
Mailing Address - Country:US
Mailing Address - Phone:541-673-0057
Mailing Address - Fax:541-673-2270
Practice Address - Street 1:770 SE KANE ST
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97470-3943
Practice Address - Country:US
Practice Address - Phone:541-673-0057
Practice Address - Fax:541-673-2270
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-18
Last Update Date:2007-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR101YP2500X, 1041C0700X, 364SP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental HealthGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR0000WCKHQMedicare ID - Type Unspecified