Healthcare Provider Details

I. General information

NPI: 1437310679
Provider Name (Legal Business Name): VICTORIA LEE STAR BSSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MRS. VICTORIA LEE YOUNGBIRD

II. Dates (important events)

Enumeration Date: 06/20/2008
Last Update Date: 10/08/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

46314 TIMINE WAY
PENDLETON OR
97801
US

IV. Provider business mailing address

PO BOX 1004
PENDLETON OR
97801-0020
US

V. Phone/Fax

Practice location:
  • Phone: 541-966-9830
  • Fax: 541-278-7572
Mailing address:
  • Phone: 541-278-3766
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number02-03-63
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number020363
License Number StateOR
# 3
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: