| Black Lotus Therapy | |
|
10 Crater Lake Ave Ste 25 Medford OR 97504-7445 | |
| (541) 500-8655 | |
| (800) 433-1396 |
| Full Name | Black Lotus Therapy |
|---|---|
| Speciality | Counselor |
| Location | 10 Crater Lake Ave Ste 25, Medford, Oregon |
| Authorized Official Name and Position | Tristin Victor (OWNER) |
| Authorized Official Contact | 5415008655 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Black Lotus Therapy Po Box 4752 Medford OR 97501-0197 Ph: (541) 500-8655 | Black Lotus Therapy 10 Crater Lake Ave Ste 25 Medford OR 97504-7445 Ph: (541) 500-8655 |
| NPI Number | 1720696289 |
|---|---|
| Provider Enumeration Date | 07/21/2020 |
| Last Update Date | 03/04/2021 |
| Certification Date | 03/04/2021 |
| Medicare PECOS PAC ID | 7315351830 |
|---|---|
| Medicare Enrollment ID | O20210125001898 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1720696289 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 101YM0800X | Counselor - Mental Health | (* (Not Available)) | Primary |
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