Provider Demographics
NPI:1477211480
Name:ROSEBURG THERAPY LLC
Entity type:Organization
Organization Name:ROSEBURG THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:JOSH
Authorized Official - Last Name:LYDON
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW L7631
Authorized Official - Phone:541-900-4285
Mailing Address - Street 1:272 NW MEDICAL LOOP STE E
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97471-5545
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:272 NW MEDICAL LOOP STE E
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97471-5545
Practice Address - Country:US
Practice Address - Phone:740-225-5342
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-12-07
Last Update Date:2021-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty