Healthcare Provider Details

I. General information

NPI: 1730647975
Provider Name (Legal Business Name): DALLAS EDDINGTON THW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/06/2019
Last Update Date: 10/29/2024
Certification Date: 10/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1160 LIBERTY ST SE
SALEM OR
97302-4143
US

IV. Provider business mailing address

1160 LIBERTY ST SE
SALEM OR
97302-4143
US

V. Phone/Fax

Practice location:
  • Phone: 855-725-5308
  • Fax:
Mailing address:
  • Phone: 855-725-5308
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number1730647975
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number1730647975
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: