Provider Demographics
NPI:1730602194
Name:IMAGINE FREEDOM, LLC
Entity type:Organization
Organization Name:IMAGINE FREEDOM, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER/CLINICIAN
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHRYSTAL
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-447-6959
Mailing Address - Street 1:190 NW 4TH ST
Mailing Address - Street 2:
Mailing Address - City:PRINEVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97754-1820
Mailing Address - Country:US
Mailing Address - Phone:541-447-6959
Mailing Address - Fax:541-447-6871
Practice Address - Street 1:190 NW 4TH ST
Practice Address - Street 2:
Practice Address - City:PRINEVILLE
Practice Address - State:OR
Practice Address - Zip Code:97754-1820
Practice Address - Country:US
Practice Address - Phone:541-447-6959
Practice Address - Fax:541-447-6871
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-18
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty