Basic Information
| Provider Information | |||||||||
| NPI: | 1558897710 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | VOLUNTEERS OF AMERICA | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 10564 SE WASHINGTON ST | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972162809 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9718060587 | ||||||||
| FaxNumber: | 5032289558 | ||||||||
| Practice Location | |||||||||
| Address1: | 10564 SE WASHINGTON ST | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972162809 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9718060587 | ||||||||
| FaxNumber: | 5032289558 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/10/2017 | ||||||||
| LastUpdateDate: | 05/10/2017 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BOWENS | ||||||||
| AuthorizedOfficialFirstName: | RATERRA | ||||||||
| AuthorizedOfficialMiddleName: | BOWENS | ||||||||
| AuthorizedOfficialTitleorPosition: | PEER RECOVERY MENTOR | ||||||||
| AuthorizedOfficialTelephone: | 9718060587 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | CRM | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251B00000X | 17-CRM-071 | OR | Y | Agencies | Case Management |
ID Information
| ID | Type | State | Issuer | Description | 17-CRM-071 | 01 | OR | ACCBO | OTHER |