Basic Information
| Provider Information | |||||||||
| NPI: | 1396822995 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DRISCOLL | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | JOSEPH | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 36 SW NYE ST | ||||||||
| Address2: | |||||||||
| City: | NEWPORT | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973653821 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412650513 | ||||||||
| FaxNumber: | 5418676548 | ||||||||
| Practice Location | |||||||||
| Address1: | 4909 S COAST HWY | ||||||||
| Address2: | |||||||||
| City: | SOUTH BEACH | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973669616 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5415745960 | ||||||||
| FaxNumber: | 5418676548 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2006 | ||||||||
| LastUpdateDate: | 06/14/2010 | ||||||||
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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 | 1041C0700X | 1189-123 | WI | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | L4579 | OR | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 213144 | 05 | OR | MEDICAID |