Healthcare Provider Details

I. General information

NPI: 1659288496
Provider Name (Legal Business Name): SAMUEL MARCOS HERNANDEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/26/2026
Last Update Date: 08/26/2026
Certification Date: 08/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

804 OLD SALEM RD NE
ALBANY OR
97321-4539
US

IV. Provider business mailing address

1109 N EVERGREEN AVE
STAYTON OR
97383-1112
US

V. Phone/Fax

Practice location:
  • Phone: 541-900-4285
  • Fax: 888-810-2993
Mailing address:
  • Phone: 503-877-7707
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: