Basic Information
| Provider Information | |||||||||
| NPI: | 1720013071 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | POLK COUNTY ALCOHOL AND DRUG | ||||||||
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| Mailing Information | |||||||||
| Address1: | 182 SW ACADEMY ST | ||||||||
| Address2: | SUITE #310 POLK COUNTY ALCOHOL AND DRUG | ||||||||
| City: | DALLAS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973381922 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5036239317 | ||||||||
| FaxNumber: | 5036232731 | ||||||||
| Practice Location | |||||||||
| Address1: | 182 SW ACADEMY | ||||||||
| Address2: | SUITE #304 | ||||||||
| City: | DALLAS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973381922 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5036239289 | ||||||||
| FaxNumber: | 5038311726 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | HANSEN | ||||||||
| AuthorizedOfficialFirstName: | GREG | ||||||||
| AuthorizedOfficialMiddleName: | P | ||||||||
| AuthorizedOfficialTitleorPosition: | POLK COUNTY ADMINISTRATIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 5036238173 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | CERTIFICATE OF APPRO | OR | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 132001 | 05 | OR | MEDICAID |