Organization
BLACK LOTUS THERAPY
Active
Organization subpart
No
Provider details
NPI number
Authorized official
TRISTIN VICTOR CSWA (OWNER)
(541) 500-8655
Entity
Organization
Contact information
Practice address
10 CRATER LAKE AVE STE 25, MEDFORD, OR 97504-7445
(541) 500-8655
(800) 433-1396
Mailing address
PO BOX 4752, MEDFORD, OR 97501-0197
(541) 500-8655
(800) 433-1396
Taxonomy
Speciality
Code
Description
License number
State
101YM0800X
Mental Health Counselor
Primary
—
—
Other
Enumeration date
07/21/2020
Last updated
03/04/2021
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