Basic Information
| Provider Information | |||||||||
| NPI: | 1851790257 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JAMES | ||||||||
| FirstName: | EDWARD | ||||||||
| MiddleName: | EUGENE | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | CADC II | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1118 OAK ST SE | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973014019 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5035854949 | ||||||||
| FaxNumber: | 5033612697 | ||||||||
| Practice Location | |||||||||
| Address1: | 2035 DAVCOR ST SE | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973021595 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5035764660 | ||||||||
| FaxNumber: | 5033612688 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/21/2014 | ||||||||
| LastUpdateDate: | 11/15/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YA0400X | 09-12-57 | OR | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 1851790257 | 05 | OR | MEDICAID |