Healthcare Provider Details

I. General information

NPI: 1841318581
Provider Name (Legal Business Name): DEPAUL YOUTH AND FAMILY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/27/2007
Last Update Date: 08/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4310 NE KILLINGSWORTH ST
PORTLAND OR
97218-1404
US

IV. Provider business mailing address

4310 NE KILLINGSWORTH ST
PORTLAND OR
97218-1404
US

V. Phone/Fax

Practice location:
  • Phone: 503-535-1150
  • Fax:
Mailing address:
  • Phone: 503-535-1150
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3245S0500X
TaxonomyChildren's Substance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: MISS SHANAKO M ALDRICH
Title or Position: GIRLS PROGRAM SUPERVISIOR
Credential: CADCI QMHA
Phone: 503-535-1150