Basic Information
| Provider Information | |||||||||
| NPI: | 1073625554 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JOSEPHINE COUNTY MENTAL HEALTH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1215 SW G ST | ||||||||
| Address2: | |||||||||
| City: | GRANTS PASS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975262544 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5414762373 | ||||||||
| FaxNumber: | 5414761526 | ||||||||
| Practice Location | |||||||||
| Address1: | 1215 SW G ST | ||||||||
| Address2: | |||||||||
| City: | GRANTS PASS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975262544 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5414762373 | ||||||||
| FaxNumber: | 5414761526 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | MAGORIAN | ||||||||
| AuthorizedOfficialFirstName: | COLEEN | ||||||||
| AuthorizedOfficialMiddleName: | A. | ||||||||
| AuthorizedOfficialTitleorPosition: | ACCOUNTING TECHNICIAN | ||||||||
| AuthorizedOfficialTelephone: | 5414762373 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TA0400X | X | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Addiction (Substance Use Disorder) | 103TB0200X | X | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Cognitive & Behavioral |
ID Information
| ID | Type | State | Issuer | Description | 096818 | 05 | OR | MEDICAID |