Healthcare Provider Details

I. General information

NPI: 1225805443
Provider Name (Legal Business Name): MARIAH B STORY CADC I
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/07/2023
Last Update Date: 12/07/2023
Certification Date: 12/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 SW 20TH ST
PENDLETON OR
97801-1869
US

IV. Provider business mailing address

PO BOX 324
ATHENA OR
97813-0324
US

V. Phone/Fax

Practice location:
  • Phone: 541-429-8261
  • Fax:
Mailing address:
  • Phone: 541-377-0003
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number8352211
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: