Provider Demographics
NPI:1932685963
Name:SOUTHERN OREGON MENTAL HEALTH SERVICES, LLC
Entity Type:Organization
Organization Name:SOUTHERN OREGON MENTAL HEALTH SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MENTAL HEALTH THERAPIST
Authorized Official - Prefix:MS
Authorized Official - First Name:NOEL
Authorized Official - Middle Name:
Authorized Official - Last Name:CHANEY
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:541-531-6312
Mailing Address - Street 1:PO BOX 4322
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97501-0165
Mailing Address - Country:US
Mailing Address - Phone:541-531-6312
Mailing Address - Fax:888-281-8465
Practice Address - Street 1:328 S CENTRAL AVE STE 211
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97501-7274
Practice Address - Country:US
Practice Address - Phone:541-531-6312
Practice Address - Fax:888-281-8465
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-12
Last Update Date:2018-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL76041041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1942580816Medicaid