1679879316 NPI number — SLADE WOLF LCSW

Table of content: SLADE WOLF LCSW (NPI 1679879316)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679879316 NPI number — SLADE WOLF LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WOLF
Provider First Name:
SLADE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WATTS
Provider Other First Name:
SLADE
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
LCSW
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1679879316
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/09/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
18616 S GRASLE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OREGON CITY
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97045-8898
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-891-6200
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
18616 S GRASLE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OREGON CITY
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97045-8898
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-891-6200
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/27/2011

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  L4203 ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)