Provider Demographics
NPI:1508940370
Name:OREGON MENTAL HEALTH SVS
Entity Type:Organization
Organization Name:OREGON MENTAL HEALTH SVS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL SOCIAL WORKER/CLINIC OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:JOAN
Authorized Official - Last Name:SELLA
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:608-835-5050
Mailing Address - Street 1:602 PLEASANT OAK DR
Mailing Address - Street 2:
Mailing Address - City:OREGON
Mailing Address - State:WI
Mailing Address - Zip Code:53575
Mailing Address - Country:US
Mailing Address - Phone:608-835-5050
Mailing Address - Fax:608-835-5050
Practice Address - Street 1:602 PLEASANT OAK DR
Practice Address - Street 2:
Practice Address - City:OREGON
Practice Address - State:WI
Practice Address - Zip Code:53575
Practice Address - Country:US
Practice Address - Phone:608-835-5050
Practice Address - Fax:608-835-5050
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Not Answered261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI2513 CERTIFICATEOtherMENTAL HEALTH OUTPUT
WI42235500Medicaid