Basic Information
| Provider Information | |||||||||
| NPI: | 1083972632 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COLEAN | ||||||||
| FirstName: | CYNTHIA | ||||||||
| MiddleName: | K | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14349 TYEE ROAD | ||||||||
| Address2: | |||||||||
| City: | UMPQUA | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97486 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5415303757 | ||||||||
| FaxNumber: | 5414403554 | ||||||||
| Practice Location | |||||||||
| Address1: | 112 EAGLE COURT | ||||||||
| Address2: | |||||||||
| City: | SUTHERLIN | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97479 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5415303757 | ||||||||
| FaxNumber: | 5414403554 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/01/2012 | ||||||||
| LastUpdateDate: | 10/25/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | N | Behavioral Health & Social Service Providers | Counselor | 101YP2500X | C2902 | OR | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 500646733 | 05 | OR | MEDICAID |