Basic Information
| Provider Information | |||||||||
| NPI: | 1336215540 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DIRECTION SERVICE COUNSELING CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 576 OLIVE ST SUITE 307 | ||||||||
| Address2: | DIRECTION SERVICE COUNSELING CENTER | ||||||||
| City: | EUGENE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413447303 | ||||||||
| FaxNumber: | 5416866283 | ||||||||
| Practice Location | |||||||||
| Address1: | 576 OLIVE ST SUITE 307 | ||||||||
| Address2: | |||||||||
| City: | EUGENE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413447303 | ||||||||
| FaxNumber: | 5416866283 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/28/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | LICTENSTEIN | ||||||||
| AuthorizedOfficialFirstName: | JACQUI | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CO DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5412844612 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PHD LCSW | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 037759 | 05 | OR | MEDICAID |