Provider Demographics
NPI:1851870224
Name:ROSEBURG COUNSELING & WELLNESS
Entity Type:Organization
Organization Name:ROSEBURG COUNSELING & WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BETTY
Authorized Official - Middle Name:LOUISE
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:541-579-8100
Mailing Address - Street 1:251 NE GARDEN VALLEY BLVD STE B
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97470-2085
Mailing Address - Country:US
Mailing Address - Phone:541-579-8100
Mailing Address - Fax:
Practice Address - Street 1:251 NE GARDEN VALLEY BLVD STE B
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97470-2085
Practice Address - Country:US
Practice Address - Phone:541-579-8100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-07
Last Update Date:2018-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL75251041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR11905531OtherCAQH