Basic Information
| Provider Information | |||||||||
| NPI: | 1740729490 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | YOUTH VILLAGES | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 368 | ||||||||
| Address2: | |||||||||
| City: | MARYLHURST | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970360368 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 2507 CHRISTIE DR. | ||||||||
| Address2: | |||||||||
| City: | LAKE OSWEGO | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97034 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5036353416 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/14/2017 | ||||||||
| LastUpdateDate: | 02/14/2017 | ||||||||
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| AuthorizedOfficialLastName: | BOLAND | ||||||||
| AuthorizedOfficialFirstName: | JORDAIN | ||||||||
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| AuthorizedOfficialTitleorPosition: | REGIONAL SUPERVISOR | ||||||||
| AuthorizedOfficialTelephone: | 5036752266 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
No ID Information.