Healthcare Provider Details

I. General information

NPI: 1689162976
Provider Name (Legal Business Name): CORVALLIS HOMELESS SHELTER COALITION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/23/2018
Last Update Date: 01/11/2024
Certification Date: 01/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2311 NW VAN BUREN AVE
CORVALLIS OR
97330-5399
US

IV. Provider business mailing address

2311 NW VAN BUREN AVE APT 5
CORVALLIS OR
97330-5393
US

V. Phone/Fax

Practice location:
  • Phone: 541-230-1297
  • Fax: 541-368-3902
Mailing address:
  • Phone: 541-230-1297
  • Fax: 541-368-3902

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: ANDREA MYHRE
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 541-602-8502