Provider Demographics
NPI:1538793591
Name:HEADWATERS THERAPY LLC
Entity type:Organization
Organization Name:HEADWATERS THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED MARRIAGE & FAMILY THERAPIS
Authorized Official - Prefix:MR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:S
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:MED, LMFT
Authorized Official - Phone:541-868-2004
Mailing Address - Street 1:927 COUNTRY CLUB RD STE 200
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97401-2272
Mailing Address - Country:US
Mailing Address - Phone:541-604-8822
Mailing Address - Fax:541-359-1134
Practice Address - Street 1:927 COUNTRY CLUB RD STE 200
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-2272
Practice Address - Country:US
Practice Address - Phone:541-604-8822
Practice Address - Fax:541-359-1134
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-28
Last Update Date:2020-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty