Basic Information
| Provider Information | |||||||||
| NPI: | 1366569998 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | POLK COUNTY MENTAL HEALTH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 182 SW ACADEMY STREET #304 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973381922 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5039311687 | ||||||||
| FaxNumber: | 5038311726 | ||||||||
| Practice Location | |||||||||
| Address1: | 182 SW ACADEMY ST | ||||||||
| Address2: | SUITE 304 | ||||||||
| City: | DALLAS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973381922 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5039311687 | ||||||||
| FaxNumber: | 5038311726 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/26/2007 | ||||||||
| LastUpdateDate: | 08/14/2008 | ||||||||
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| AuthorizedOfficialLastName: | SCHRAM | ||||||||
| AuthorizedOfficialFirstName: | BARBARA | ||||||||
| AuthorizedOfficialMiddleName: | JEAN | ||||||||
| AuthorizedOfficialTitleorPosition: | CASE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 5039311687 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | BS | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251B00000X | Y | Agencies | Case Management |
No ID Information.