Healthcare Provider Details

I. General information

NPI: 1821331943
Provider Name (Legal Business Name): DALLAS D NEIGHBORS CADC II, QMHA-R
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/27/2013
Last Update Date: 07/30/2020
Certification Date: 07/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2045 SILVERTON RD NE
SALEM OR
97301-0100
US

IV. Provider business mailing address

2045 SILVERTON RD NE
SALEM OR
97301-0100
US

V. Phone/Fax

Practice location:
  • Phone: 503-588-5351
  • Fax:
Mailing address:
  • Phone: 503-588-5351
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number11-06-54
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number20-QMHA-R-0491
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: