MEDICARE: POLK COUNTY MENTAL HEALTH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	04-R-19	OR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	04-R-19	OTHER	OR	CADC-II ID NUMBER

General Provider Information

NPI Number	:	1295857977
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	POLK COUNTY MENTAL HEALTH

Provider Business Mailing Address
First Line	:	557 21ST ST SE
Second Line	:
City	:	SALEM
State	:	OR
Zip	:	97301-6526
Country	:	US
Telephone Number	:	503-991-0226
Fax Number	:

Provider Business Practice Location Address
First Line	:	557 21ST ST SE
Second Line	:
City	:	SALEM
State	:	OR
Zip	:	97301-6526
Country	:	US
Telephone Number	:	503-991-0226
Fax Number	:

Authorized Official
Title or Position	:	ADDICTIONS COUNSELOR
Name	:	SUSAN MARIE KLEIN
Credential	:	CADC-II QMHA BS
Telephone Number	:	503-623-9289

Provider Enumeration Date	:	04/04/2007
Last Update Date	:	08/14/2008

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