Provider Demographics
NPI:1720696289
Name:BLACK LOTUS THERAPY
Entity Type:Organization
Organization Name:BLACK LOTUS THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TRISTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:VICTOR
Authorized Official - Suffix:
Authorized Official - Credentials:CSWA
Authorized Official - Phone:541-500-8655
Mailing Address - Street 1:PO BOX 4752
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97501-0197
Mailing Address - Country:US
Mailing Address - Phone:541-500-8655
Mailing Address - Fax:800-433-1396
Practice Address - Street 1:10 CRATER LAKE AVE STE 25
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-7445
Practice Address - Country:US
Practice Address - Phone:541-500-8655
Practice Address - Fax:800-433-1396
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-21
Last Update Date:2021-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty