Basic Information
| Provider Information | |||||||||
| NPI: | 1356757108 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | YOUTH VILLAGES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15544 S CLACKAMAS RIVER DR | ||||||||
| Address2: | |||||||||
| City: | OREGON CITY | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970459490 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5039745816 | ||||||||
| FaxNumber: | 5036070211 | ||||||||
| Practice Location | |||||||||
| Address1: | 15544 S CLACKAMAS RIVER DR | ||||||||
| Address2: | |||||||||
| City: | OREGON CITY | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970459490 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5039745816 | ||||||||
| FaxNumber: | 5036070211 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/01/2014 | ||||||||
| LastUpdateDate: | 07/01/2014 | ||||||||
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| AuthorizedOfficialLastName: | MENDOZA CABELLO | ||||||||
| AuthorizedOfficialFirstName: | BERENICE | ||||||||
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| AuthorizedOfficialTitleorPosition: | BILINGUAL INTERCEPT SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 5039745816 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MSW,QMHP | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.