Healthcare Provider Details

I. General information

NPI: 1659235091
Provider Name (Legal Business Name): CASSEY IMHOLT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/10/2025
Last Update Date: 12/10/2025
Certification Date: 12/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

256 SE 2ND AVE
HILLSBORO OR
97123-4017
US

IV. Provider business mailing address

1174 CORNUCOPIA ST NW STE 240
SALEM OR
97304-3193
US

V. Phone/Fax

Practice location:
  • Phone: 971-301-4411
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number114727
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: