Basic Information
| Provider Information | |||||||||
| NPI: | 1215139720 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CREEKSIDE COUNSELING INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4169 | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5033714160 | ||||||||
| FaxNumber: | 5033759727 | ||||||||
| Practice Location | |||||||||
| Address1: | 2586 12TH PLACE SE | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5033714160 | ||||||||
| FaxNumber: | 5033759727 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/05/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | LAHARTY | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 5033714160 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | MS CDS III | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.