Provider Demographics
NPI:1659355865
Name:KLAMATH BEHAVORIAL HEALTH AND WELLNESS
Entity Type:Organization
Organization Name:KLAMATH BEHAVORIAL HEALTH AND WELLNESS
Other - Org Name:KLAMATH COUNTY MENTAL HEALTH
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:BUNGER
Authorized Official - Suffix:
Authorized Official - Credentials:MED
Authorized Official - Phone:541-882-7291
Mailing Address - Street 1:3314 VANDENBERG RD
Mailing Address - Street 2:
Mailing Address - City:KLAMATH FALLS
Mailing Address - State:OR
Mailing Address - Zip Code:97603-3730
Mailing Address - Country:US
Mailing Address - Phone:541-882-7291
Mailing Address - Fax:541-883-4213
Practice Address - Street 1:3314 VANDENBERG RD
Practice Address - Street 2:
Practice Address - City:KLAMATH FALLS
Practice Address - State:OR
Practice Address - Zip Code:97603-3730
Practice Address - Country:US
Practice Address - Phone:541-882-7291
Practice Address - Fax:541-883-4213
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-01
Last Update Date:2013-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR101YM0800X, 261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR101568Medicaid
OR101568Medicaid