Healthcare Provider Details

I. General information

NPI: 1881832095
Provider Name (Legal Business Name): INTEGRATED YOUTHCARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/26/2009
Last Update Date: 07/16/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

673 NW JACKSON AVE
CORVALLIS OR
97330-4832
US

IV. Provider business mailing address

673 NW JACKSON AVE
CORVALLIS OR
97330-4832
US

V. Phone/Fax

Practice location:
  • Phone: 541-230-1630
  • Fax:
Mailing address:
  • Phone: 541-230-1630
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberL4404
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberC2485
License Number StateOR
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberC2422
License Number StateOR
# 4
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number200950078NP
License Number StateOR

VIII. Authorized Official

Name: RON WIEBE
Title or Position: DIRECTOR OF OPERATIONS
Credential:
Phone: 541-230-1630