Basic Information
Provider Information | |||||||||
NPI: | 1396080933 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CASEY | ||||||||
FirstName: | DAVID | ||||||||
MiddleName: | JAMES | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | LCSW | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 51377 SW OLD PORTLAND RD | ||||||||
Address2: |   | ||||||||
City: | SCAPPOOSE | ||||||||
State: | OR | ||||||||
PostalCode: | 970564023 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5034184222 | ||||||||
FaxNumber: | 5034184223 | ||||||||
Practice Location | |||||||||
Address1: | 2586 12TH PL SE | ||||||||
Address2: |   | ||||||||
City: | SALEM | ||||||||
State: | OR | ||||||||
PostalCode: | 973022536 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5033714160 | ||||||||
FaxNumber: | 5033759727 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/09/2012 | ||||||||
LastUpdateDate: | 04/18/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | L8114 | OR | Y |   | Behavioral Health & Social Service Providers | Social Worker | Clinical | 101YA0400X | 12-09-07 | OR | N |   | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.