Provider Demographics
NPI:1730946542
Name:MID-WILLAMETTE FAMILY AND INDIVIDUAL THERAPY SERVICES LLC
Entity type:Organization
Organization Name:MID-WILLAMETTE FAMILY AND INDIVIDUAL THERAPY SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CRISSANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:STEPHEN
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:971-575-6640
Mailing Address - Street 1:3437 COVINGTON ST NE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97305-1507
Mailing Address - Country:US
Mailing Address - Phone:971-757-6640
Mailing Address - Fax:
Practice Address - Street 1:698 12TH ST SE STE 210
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-4010
Practice Address - Country:US
Practice Address - Phone:971-757-6640
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-02-28
Last Update Date:2024-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty