Basic Information
| Provider Information | |||||||||
| NPI: | 1851639322 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WARD | ||||||||
| FirstName: | JOY | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SALAIZ OTERO | ||||||||
| OtherFirstName: | JOY | ||||||||
| OtherMiddleName: | LYNN | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 272 NW MEDICAL LOOP | ||||||||
| Address2: | SUITE E | ||||||||
| City: | ROSEBURG | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974715597 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5414403532 | ||||||||
| FaxNumber: | 5414403554 | ||||||||
| Practice Location | |||||||||
| Address1: | 337 SE FOWLER ST | ||||||||
| Address2: | |||||||||
| City: | ROSEBURG | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974704348 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5414403532 | ||||||||
| FaxNumber: | 5414403554 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/17/2013 | ||||||||
| LastUpdateDate: | 06/23/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
ID Information
| ID | Type | State | Issuer | Description | 500664434 | 05 | OR | MEDICAID |