Healthcare Provider Details

I. General information

NPI: 1659758167
Provider Name (Legal Business Name): ADAGIO THERAPY CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/05/2015
Last Update Date: 05/05/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

388 STATE ST SUITE 707
SALEM OR
97301-3866
US

IV. Provider business mailing address

388 STATE ST SUITE 707
SALEM OR
97301-3866
US

V. Phone/Fax

Practice location:
  • Phone: 818-253-9264
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number2518
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberL6113
License Number StateOR

VIII. Authorized Official

Name: DR. MARTHA WANG
Title or Position: CLINICAL PSYCHOLOGIST
Credential: PHD
Phone: 818-253-9264