Healthcare Provider Details

I. General information

NPI: 1962190546
Provider Name (Legal Business Name): KIM Y. WAITERS CADC REGISTRANT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2023
Last Update Date: 05/13/2025
Certification Date: 05/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 S MAIN ST
LEBANON OR
97355-3109
US

IV. Provider business mailing address

PO BOX 100
ALBANY OR
97321-0031
US

V. Phone/Fax

Practice location:
  • Phone: 541-451-5932
  • Fax:
Mailing address:
  • Phone: 541-967-3866
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number24-04-11094
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: