Provider Demographics
NPI:1679765333
Name:LINEBACK, PAUL R (MS, LPC, LMHC)
Entity Type:Individual
Prefix:MR
First Name:PAUL
Middle Name:R
Last Name:LINEBACK
Suffix:
Gender:M
Credentials:MS, LPC, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97470-0001
Mailing Address - Country:US
Mailing Address - Phone:541-391-9991
Mailing Address - Fax:
Practice Address - Street 1:1299 NW ELLAN ST STE 3
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97470-2031
Practice Address - Country:US
Practice Address - Phone:541-391-9991
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-15
Last Update Date:2011-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH00004271101YM0800X
ORC1198101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health