Basic Information
| Provider Information | |||||||||
| NPI: | 1922066463 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COLUMBIA COMMUNITY MENTAL HEALTH | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1234 | ||||||||
| Address2: | |||||||||
| City: | ST HELENS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970518234 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5033975211 | ||||||||
| FaxNumber: | 5033975373 | ||||||||
| Practice Location | |||||||||
| Address1: | 58646 MCNULTY WAY | ||||||||
| Address2: | |||||||||
| City: | ST HELENS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970516210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5033975211 | ||||||||
| FaxNumber: | 5033975373 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2006 | ||||||||
| LastUpdateDate: | 03/25/2022 | ||||||||
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| AuthorizedOfficialLastName: | JACOBSON | ||||||||
| AuthorizedOfficialFirstName: | TODD | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5033975211 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 03/25/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 103TB0200X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Cognitive & Behavioral | 1041C0700X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical | 101YM0800X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 123190 | 05 | OR | MEDICAID |