Healthcare Provider Details

I. General information

NPI: 1982749743
Provider Name (Legal Business Name): MARYDALE G SALSTON PH.D., LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/20/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4455 NE HIGHWAY 20
CORVALLIS OR
97330-9695
US

IV. Provider business mailing address

335 CHICAGO ST SE
ALBANY OR
97321-4852
US

V. Phone/Fax

Practice location:
  • Phone: 541-758-5947
  • Fax: 541-757-1944
Mailing address:
  • Phone: 541-791-4876
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberT0518
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: