Healthcare Provider Details

I. General information

NPI: 1356322713
Provider Name (Legal Business Name): TAHANA WHITECROW FOUNDATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/10/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2350 WALLACE RD NW
SALEM OR
97304-2127
US

IV. Provider business mailing address

2350 WALLACE RD NW
SALEM OR
97304-2127
US

V. Phone/Fax

Practice location:
  • Phone: 503-585-0564
  • Fax: 503-585-3302
Mailing address:
  • Phone: 503-585-0564
  • Fax: 503-585-3302

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MS. MELANIE MAE SMITH
Title or Position: DIRECTOR SUBSTANCE ABUSE COUNSELOR
Credential: CADCII NCACI
Phone: 503-585-0564