1770603532 NPI number — POLK COUNTY MENTAL HEALTH

Table of content: (NPI 1770603532)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770603532 NPI number — POLK COUNTY MENTAL HEALTH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
POLK COUNTY MENTAL HEALTH
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1770603532
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/02/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
182 SW ACADEMY ST STE 304
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97338-1900
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-851-6737
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
182 SW ACADEMY ST STE 304
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DALLAS
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97338-1900
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-623-9289
Provider Business Practice Location Address Fax Number:
503-831-1726
Provider Enumeration Date:
03/29/2007

Additional Information

Authorized Official

Authorized Official Last Name:
GUTIERREZ
Authorized Official First Name:
SERGIO
Authorized Official Middle Name:
Authorized Official Title or Position:
MENTAL HEALTH COUNSELOR I
Authorized Official Telephone Number:
503-623-9289

Provider Taxonomy Codes

  • Taxonomy code: 261QR0405X , with the licence number:  00-07-15 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 00-07-15 . This is a "CADC I" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".




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