Provider Demographics
NPI:1194116715
Name:BLEMMEL, CARLY (MSHR LPC)
Entity type:Individual
Prefix:
First Name:CARLY
Middle Name:
Last Name:BLEMMEL
Suffix:
Gender:F
Credentials:MSHR LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 740
Mailing Address - Street 2:
Mailing Address - City:TALIHINA
Mailing Address - State:OK
Mailing Address - Zip Code:74571-0740
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2589 NW EDENBOWER BLVD
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97471-6224
Practice Address - Country:US
Practice Address - Phone:541-839-1345
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-18
Last Update Date:2023-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK7774101YM0800X
324500000X
ORC6861101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility