Provider Demographics
NPI:1942035126
Name:MID-WILLAMETTE VALLEY TRANSGENDER SUPPORT NETWORK
Entity type:Organization
Organization Name:MID-WILLAMETTE VALLEY TRANSGENDER SUPPORT NETWORK
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:GRANT & HEALTH PROGRAM COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:DHARMA
Authorized Official - Middle Name:LERIA
Authorized Official - Last Name:MIRZA
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:541-780-3307
Mailing Address - Street 1:260 SW MADISON AVE STE 110
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97333-4728
Mailing Address - Country:US
Mailing Address - Phone:541-780-3307
Mailing Address - Fax:
Practice Address - Street 1:260 SW MADISON AVE STE 110
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97333-4728
Practice Address - Country:US
Practice Address - Phone:541-780-3307
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-09-05
Last Update Date:2025-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No175T00000XOther Service ProvidersPeer Specialist
No251B00000XAgenciesCase Management
No251V00000XAgenciesVoluntary or Charitable
No261QR1100XAmbulatory Health Care FacilitiesClinic/CenterResearch