Provider Demographics
NPI:1679957708
Name:SECOND WIND MENTAL HEALTH CLINIC
Entity Type:Organization
Organization Name:SECOND WIND MENTAL HEALTH CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SINGLE MEMBER LLC
Authorized Official - Prefix:
Authorized Official - First Name:TAMARA
Authorized Official - Middle Name:
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:541-679-0366
Mailing Address - Street 1:11 SW BRANTLEY DRIVE
Mailing Address - Street 2:
Mailing Address - City:WINSTON
Mailing Address - State:OR
Mailing Address - Zip Code:97496
Mailing Address - Country:US
Mailing Address - Phone:541-679-0366
Mailing Address - Fax:541-679-4821
Practice Address - Street 1:11 SW BRANTLEY DRIVE
Practice Address - Street 2:
Practice Address - City:WINSTON
Practice Address - State:OR
Practice Address - Zip Code:97496
Practice Address - Country:US
Practice Address - Phone:541-679-0366
Practice Address - Fax:541-679-4821
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-18
Last Update Date:2015-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200550033NP261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR363LP0808XMedicaid
OR363LP0808XMedicaid