Provider Demographics
NPI:1154944536
Name:FUNCTIONAL MENTAL HEALTH LLC
Entity type:Organization
Organization Name:FUNCTIONAL MENTAL HEALTH LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PMHNP
Authorized Official - Prefix:
Authorized Official - First Name:MCKENZIE
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-326-8078
Mailing Address - Street 1:11 SW BRANTLEY DR
Mailing Address - Street 2:
Mailing Address - City:WINSTON
Mailing Address - State:OR
Mailing Address - Zip Code:97496-4526
Mailing Address - Country:US
Mailing Address - Phone:541-679-0366
Mailing Address - Fax:541-679-4821
Practice Address - Street 1:11 SW BRANTLEY DR
Practice Address - Street 2:
Practice Address - City:WINSTON
Practice Address - State:OR
Practice Address - Zip Code:97496-4526
Practice Address - Country:US
Practice Address - Phone:541-679-0366
Practice Address - Fax:541-679-4821
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-20
Last Update Date:2021-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty