Healthcare Provider Details

I. General information

NPI: 1316781735
Provider Name (Legal Business Name): STONEWALL BEHAVIORAL HEALTH & MENTAL WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/20/2024
Last Update Date: 07/09/2024
Certification Date: 07/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

826 SE 10TH ST
PENDLETON OR
97801-3246
US

IV. Provider business mailing address

826 SE 10TH ST
PENDLETON OR
97801-3246
US

V. Phone/Fax

Practice location:
  • Phone: 541-539-3214
  • Fax:
Mailing address:
  • Phone: 765-354-8410
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: NATHAN T SMITH
Title or Position: OWNER
Credential: LCSW
Phone: 765-354-8410