Healthcare Provider Details

I. General information

NPI: 1053624387
Provider Name (Legal Business Name): IMPACT NW
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/15/2010
Last Update Date: 08/17/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7211 SE 62ND AVE
PORTLAND OR
97206
US

IV. Provider business mailing address

PO BOX 33530
PORTLAND OR
97292-3530
US

V. Phone/Fax

Practice location:
  • Phone: 503-721-6776
  • Fax: 971-254-8969
Mailing address:
  • Phone: 503-294-7400
  • Fax: 503-802-0046

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: MS. AMANDA LEE ADAMS
Title or Position: LTK PROJECT COORDINATOR
Credential:
Phone: 541-227-8888