Provider Demographics
NPI:1578945515
Name:DEEP RIVER COUNSELING LLC
Entity Type:Organization
Organization Name:DEEP RIVER COUNSELING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JUDITH
Authorized Official - Middle Name:L
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MA, LPC, ATR
Authorized Official - Phone:541-217-0890
Mailing Address - Street 1:PO BOX 1478
Mailing Address - Street 2:
Mailing Address - City:COOS BAY
Mailing Address - State:OR
Mailing Address - Zip Code:97420-0331
Mailing Address - Country:US
Mailing Address - Phone:541-217-0890
Mailing Address - Fax:541-266-8408
Practice Address - Street 1:375 PARK AVE STE B
Practice Address - Street 2:
Practice Address - City:COOS BAY
Practice Address - State:OR
Practice Address - Zip Code:97420-2244
Practice Address - Country:US
Practice Address - Phone:541-217-0890
Practice Address - Fax:541-266-8408
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-26
Last Update Date:2015-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC2373101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty