Basic Information
| Provider Information | |||||||||
| NPI: | 1932301173 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MARION COUNTY HEALTH DEPARTMENT | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | PSYCHIATRIC CRISIS CENTER | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1073 OAK ST SE | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973014018 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5035854949 | ||||||||
| FaxNumber: | 5035854965 | ||||||||
| Practice Location | |||||||||
| Address1: | 1073 OAK ST SE | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973014018 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5035854949 | ||||||||
| FaxNumber: | 5035854965 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KNOWLES | ||||||||
| AuthorizedOfficialFirstName: | IRINA | ||||||||
| AuthorizedOfficialMiddleName: | GENNADYEVNA | ||||||||
| AuthorizedOfficialTitleorPosition: | MENTAL HEALTH SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 5035854949 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | QMHP | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
No ID Information.