Healthcare Provider Details

I. General information

NPI: 1437518487
Provider Name (Legal Business Name): CAROL GREENE CADC II
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/18/2016
Last Update Date: 03/04/2020
Certification Date: 03/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17 SW FRAZER AVE SUITE 282
PENDLETON OR
97801-2163
US

IV. Provider business mailing address

17 SW FRAZER AVE SUITE 282
PENDLETON OR
97801-2163
US

V. Phone/Fax

Practice location:
  • Phone: 541-276-7824
  • Fax: 541-278-0353
Mailing address:
  • Phone: 541-276-7824
  • Fax: 541-278-0353

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number11-12-81
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: