Provider Demographics
NPI:1851567655
Name:LIBERTY MENTAL HEALTH CLINIC
Entity Type:Organization
Organization Name:LIBERTY MENTAL HEALTH CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:LOREN
Authorized Official - Middle Name:S
Authorized Official - Last Name:MELTZER
Authorized Official - Suffix:
Authorized Official - Credentials:JD,LPC,CADC
Authorized Official - Phone:503-302-4126
Mailing Address - Street 1:1247 COMMERCIAL ST SE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302-4203
Mailing Address - Country:US
Mailing Address - Phone:503-581-0463
Mailing Address - Fax:503-581-1669
Practice Address - Street 1:145 WILSON ST S
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-4232
Practice Address - Country:US
Practice Address - Phone:503-581-0463
Practice Address - Fax:503-581-1669
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-01
Last Update Date:2008-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL3352-C1512251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health