Provider Demographics
NPI:1972211324
Name:FLOSS MENTAL HEALTH, LLC
Entity Type:Organization
Organization Name:FLOSS MENTAL HEALTH, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:
Authorized Official - Last Name:WITHAM
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-C, PMHNP-BC
Authorized Official - Phone:503-455-7656
Mailing Address - Street 1:1092 NW BASCO AVE
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97471-6164
Mailing Address - Country:US
Mailing Address - Phone:503-455-7656
Mailing Address - Fax:503-457-0645
Practice Address - Street 1:1299 NW ELLAN ST STE 3
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97470-2031
Practice Address - Country:US
Practice Address - Phone:503-455-7656
Practice Address - Fax:503-457-0645
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-11-14
Last Update Date:2022-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty