Basic Information
| Provider Information | |||||||||
| NPI: | 1174090294 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FOSTER | ||||||||
| FirstName: | DANIEL | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | FOSTER | ||||||||
| OtherFirstName: | DAN | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | QMHP | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 965 TUCKER RD | ||||||||
| Address2: | |||||||||
| City: | HOOD RIVER | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970319591 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413866665 | ||||||||
| FaxNumber: | 5412987996 | ||||||||
| Practice Location | |||||||||
| Address1: | 401 E 3RD ST STE 101 | ||||||||
| Address2: | |||||||||
| City: | THE DALLES | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970582563 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412982101 | ||||||||
| FaxNumber: | 5412987996 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/26/2018 | ||||||||
| LastUpdateDate: | 08/11/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 08/11/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.