Basic Information
| Provider Information | |||||||||
| NPI: | 1376710491 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SANCHEZ | ||||||||
| FirstName: | JOSE | ||||||||
| MiddleName: | LUIS | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | CADC11 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 182 S.W. ACADEMY | ||||||||
| Address2: | SUITE 304 | ||||||||
| City: | DALLAS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97338 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5036231886 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 182 S.W. ACADEMY | ||||||||
| Address2: | SUITE 304 | ||||||||
| City: | DALLAS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97338 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5036231886 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/08/2008 | ||||||||
| LastUpdateDate: | 01/15/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | N | Behavioral Health & Social Service Providers | Counselor | 101YA0400X | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YM0800X | N | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 02- P-06 | 01 | OR | CADCII THE ADDICTION COUNSELOR CERTIFICATION BOARD OF OREGON | OTHER |