Basic Information
| Provider Information | |||||||||
| NPI: | 1447643556 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CRC ALLIED HEALTH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 808 SW ALDER ST | ||||||||
| Address2: | STE #300 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972053133 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032262203 | ||||||||
| FaxNumber: | 5032234231 | ||||||||
| Practice Location | |||||||||
| Address1: | 808 SW ALDER ST | ||||||||
| Address2: | STE #300 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972053133 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032262203 | ||||||||
| FaxNumber: | 5032234231 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/13/2015 | ||||||||
| LastUpdateDate: | 03/13/2015 | ||||||||
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| AuthorizedOfficialLastName: | TIERNY | ||||||||
| AuthorizedOfficialFirstName: | MIKE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CLINICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5032262203 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | BS CADC II | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | 130906 | OR | Y | Agencies | Community/Behavioral Health |
No ID Information.