Healthcare Provider Details

I. General information

NPI: 1649649211
Provider Name (Legal Business Name): CAROL L STEPHENS CADC I
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/24/2015
Last Update Date: 10/10/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 N.E. MANZANITA AVE
GRANTS PASS OR
97526-1400
US

IV. Provider business mailing address

109 N.E. MANZANITA AVE
GRANTS PASS OR
97526-1400
US

V. Phone/Fax

Practice location:
  • Phone: 541-479-8847
  • Fax: 541-471-2679
Mailing address:
  • Phone: 541-479-8847
  • Fax: 541-471-2679

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number15-01-12
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VII. Legacy identifiers

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

# 1
Identifier101YA0400X
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer
# 2
Identifier500701179
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: