Basic Information
| Provider Information | |||||||||
| NPI: | 1649500190 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HAPP | ||||||||
| FirstName: | THERESA | ||||||||
| MiddleName: | MAUREEN | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | JOHNSON | ||||||||
| OtherFirstName: | THERESA | ||||||||
| OtherMiddleName: | MAUREEN | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1146 NE FREEMONT AVE | ||||||||
| Address2: | |||||||||
| City: | ROSEBURG | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974703213 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9712210783 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 621 W MADRONE ST | ||||||||
| Address2: | |||||||||
| City: | ROSEBURG | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974703090 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5414403532 | ||||||||
| FaxNumber: | 5419573790 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/06/2010 | ||||||||
| LastUpdateDate: | 08/14/2012 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | A2547 | 01 | OR | CERTIFICATE OF CLINICAL SOCIAL WORK ASSOCIATE | OTHER |