Basic Information
| Provider Information | |||||||||
| NPI: | 1790223113 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WESTON | ||||||||
| FirstName: | ASHFORD | ||||||||
| MiddleName: | DURHAM | ||||||||
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| Credential: | QMHP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 419 E 7TH ST STE 207 | ||||||||
| Address2: | |||||||||
| City: | THE DALLES | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970582676 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412965452 | ||||||||
| FaxNumber: | 5412961537 | ||||||||
| Practice Location | |||||||||
| Address1: | 9300 NE OAK VIEW DR | ||||||||
| Address2: | |||||||||
| City: | VANCOUVER | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986626157 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3608699590 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/06/2017 | ||||||||
| LastUpdateDate: | 07/07/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/07/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101Y00000X | WA | Y | Behavioral Health & Social Service Providers | Counselor |
ID Information
| ID | Type | State | Issuer | Description | 1699745794 | 05 | OR | MEDICAID |