Provider Demographics
NPI:1811716202
Name:PRIMAL PATH THERAPY LLC
Entity type:Organization
Organization Name:PRIMAL PATH THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MCF THERAPIST ASSOCIATE
Authorized Official - Prefix:
Authorized Official - First Name:MELANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:SELLERS
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:541-625-4361
Mailing Address - Street 1:27075 CLEAR LAKE RD
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97402-9443
Mailing Address - Country:US
Mailing Address - Phone:562-641-6992
Mailing Address - Fax:
Practice Address - Street 1:2355 STATE ST STE 101
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-4541
Practice Address - Country:US
Practice Address - Phone:541-625-4361
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-10-03
Last Update Date:2024-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)