Basic Information
| Provider Information | |||||||||
| NPI: | 1659380145 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TILLAMOOK FAMILY COUNSELING CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 906 MAIN AVE | ||||||||
| Address2: | |||||||||
| City: | TILLAMOOK | ||||||||
| State: | OR | ||||||||
| PostalCode: | 971413816 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5038428201 | ||||||||
| FaxNumber: | 5038151870 | ||||||||
| Practice Location | |||||||||
| Address1: | 906 MAIN AVE | ||||||||
| Address2: | |||||||||
| City: | TILLAMOOK | ||||||||
| State: | OR | ||||||||
| PostalCode: | 971413816 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5038428201 | ||||||||
| FaxNumber: | 5038151870 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/05/2006 | ||||||||
| LastUpdateDate: | 10/03/2007 | ||||||||
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| AuthorizedOfficialLastName: | HANNA-WILLIAMS | ||||||||
| AuthorizedOfficialFirstName: | FRANK | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5038428201 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QD1600X | N | Ambulatory Health Care Facilities | Clinic/Center | Developmental Disabilities | 261QM0850X | N | Ambulatory Health Care Facilities | Clinic/Center | Adult Mental Health | 261QM0855X | N | Ambulatory Health Care Facilities | Clinic/Center | Adolescent and Children Mental Health | 261QM0801X | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | 183822 | 05 | OR | MEDICAID | 197749 | 05 | OR | MEDICAID |