Basic Information
| Provider Information | |||||||||
| NPI: | 1326432154 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CRC HEALTH DBA ALLIED HEALTH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 808 SW ALDER STREET SUITE 300 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032262203 | ||||||||
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| Practice Location | |||||||||
| Address1: | 808 SW ALDER ST STE 300 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972053133 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032262203 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/18/2015 | ||||||||
| LastUpdateDate: | 03/18/2015 | ||||||||
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| AuthorizedOfficialLastName: | TIERNEY | ||||||||
| AuthorizedOfficialFirstName: | MIKE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CLINIC DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5032262203 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CCRC HEALTH GROUP | ||||||||
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| AuthorizedOfficialCredential: | CADCII | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | OR | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 251S00000X | Y | Agencies | Community/Behavioral Health |
No ID Information.