Healthcare Provider Details

I. General information

NPI: 1063996072
Provider Name (Legal Business Name): DANIEL DIRK
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/17/2018
Last Update Date: 09/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

777 NE 7TH ST STE 107
GRANTS PASS OR
97526-1632
US

IV. Provider business mailing address

320 SW L ST
GRANTS PASS OR
97526-2928
US

V. Phone/Fax

Practice location:
  • Phone: 541-450-0493
  • Fax:
Mailing address:
  • Phone: 541-450-0493
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: DANIEL DIRK
Title or Position: SOLE PROPTERTOR
Credential: LMFT
Phone: 541-450-0493