Provider Demographics
NPI:1841807484
Name:SOUTH VALLEY THERAPY, LLC
Entity Type:Organization
Organization Name:SOUTH VALLEY THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DAVIDE
Authorized Official - Middle Name:J
Authorized Official - Last Name:COSTLEY
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:541-525-1010
Mailing Address - Street 1:5649 E ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OR
Mailing Address - Zip Code:97478-5417
Mailing Address - Country:US
Mailing Address - Phone:541-525-1010
Mailing Address - Fax:
Practice Address - Street 1:1991 GARDEN AVE
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97403-1934
Practice Address - Country:US
Practice Address - Phone:541-525-1010
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-28
Last Update Date:2020-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500662974Medicaid