Healthcare Provider Details

I. General information

NPI: 1720013071
Provider Name (Legal Business Name): POLK COUNTY ALCOHOL AND DRUG
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/12/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

182 SW ACADEMY SUITE #304
DALLAS OR
97338-1922
US

IV. Provider business mailing address

182 SW ACADEMY ST SUITE #310 POLK COUNTY ALCOHOL AND DRUG
DALLAS OR
97338-1922
US

V. Phone/Fax

Practice location:
  • Phone: 503-623-9289
  • Fax: 503-831-1726
Mailing address:
  • Phone: 503-623-9317
  • Fax: 503-623-2731

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCERTIFICATE OF APPRO
License Number StateOR

VIII. Authorized Official

Name: MR. GREG P HANSEN
Title or Position: POLK COUNTY ADMINISTRATIVE OFFICER
Credential:
Phone: 503-623-8173