Basic Information
| Provider Information | |||||||||
| NPI: | 1770603532 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | POLK COUNTY MENTAL HEALTH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 182 SW ACADEMY ST STE 304 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973381900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5038516737 | ||||||||
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| Practice Location | |||||||||
| Address1: | 182 SW ACADEMY ST STE 304 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973381900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5036239289 | ||||||||
| FaxNumber: | 5038311726 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/29/2007 | ||||||||
| LastUpdateDate: | 07/02/2008 | ||||||||
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| AuthorizedOfficialLastName: | GUTIERREZ | ||||||||
| AuthorizedOfficialFirstName: | SERGIO | ||||||||
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| AuthorizedOfficialTitleorPosition: | MENTAL HEALTH COUNSELOR I | ||||||||
| AuthorizedOfficialTelephone: | 5036239289 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0405X | 00-07-15 | OR | Y | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder |
ID Information
| ID | Type | State | Issuer | Description | 00-07-15 | 01 | OR | CADC I | OTHER |