Healthcare Provider Details

I. General information

NPI: 1912121526
Provider Name (Legal Business Name): SALEM PSYCHIATRIC ASSOCIATES PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/13/2007
Last Update Date: 10/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

821 SAGINAW ST S
SALEM OR
97302-4121
US

IV. Provider business mailing address

821 SAGINAW ST S
SALEM OR
97302-4121
US

V. Phone/Fax

Practice location:
  • Phone: 503-589-4046
  • Fax: 503-362-9671
Mailing address:
  • Phone: 503-315-8646
  • Fax: 503-798-9560

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103TM1800X
TaxonomyIntellectual & Developmental Disabilities Psychologist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: CAMILLE SOLEIL
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 503-798-9541