Provider Demographics
NPI:1023138088
Name:COTTAGE GROVE COUNSELING CLINIC, INC.
Entity type:Organization
Organization Name:COTTAGE GROVE COUNSELING CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:N
Authorized Official - Last Name:REISS
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:541-686-8060
Mailing Address - Street 1:PO BOX 786
Mailing Address - Street 2:
Mailing Address - City:COTTAGE GROVE
Mailing Address - State:OR
Mailing Address - Zip Code:97424-0033
Mailing Address - Country:US
Mailing Address - Phone:541-942-8060
Mailing Address - Fax:541-942-9849
Practice Address - Street 1:411 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:COTTAGE GROVE
Practice Address - State:OR
Practice Address - Zip Code:97424-2060
Practice Address - Country:US
Practice Address - Phone:541-942-8060
Practice Address - Fax:541-942-9849
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty