Basic Information
Provider Information | |||||||||
NPI: | 1841424538 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MEADE | ||||||||
FirstName: | BENJAMIN | ||||||||
MiddleName: | P | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MSW, LCSW | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 36 SW NYE ST | ||||||||
Address2: |   | ||||||||
City: | NEWPORT | ||||||||
State: | OR | ||||||||
PostalCode: | 973653821 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5412650445 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 4422 NE DEVILS LAKE BLVD | ||||||||
Address2: | SUITE 2 | ||||||||
City: | LINCOLN CITY | ||||||||
State: | OR | ||||||||
PostalCode: | 973675000 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5412654196 | ||||||||
FaxNumber: | 5419941882 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/08/2009 | ||||||||
LastUpdateDate: | 06/04/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 06/04/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | L5748 | OR | Y |   | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
ID | Type | State | Issuer | Description | 500664110 | 05 | OR |   | MEDICAID |