Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 101YM0800X | Mental Health Counselor |
NPI | 1003059296 |
---|---|
Provider Name | Therese N Mastin |
First Address | Cottage Grove, OR 97424-1307 |
Second Address | Cottage Grove, OR 97424-1416 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 17/04/2009 |
Last Update Date | 01/09/2017 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
019047 | (05) | OR |