Healthcare Provider Details

I. General information

NPI: 1629223243
Provider Name (Legal Business Name): PROFESSIONAL THERAPEUTIC COMMUNITY NETWORK, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/24/2008
Last Update Date: 05/16/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2905 RIVER RD S
SALEM OR
97302-9754
US

IV. Provider business mailing address

2905 RIVER RD S
SALEM OR
97302-9754
US

V. Phone/Fax

Practice location:
  • Phone: 503-391-7175
  • Fax: 503-585-3303
Mailing address:
  • Phone: 503-391-7175
  • Fax: 503-585-3303

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code253J00000X
TaxonomyFoster Care Agency
License Number
License Number StateOR
# 3
Primary TaxonomyN
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number StateOR
# 4
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number StateOR

VIII. Authorized Official

Name: MR. JESSE WATSON
Title or Position: CEO
Credential: MA
Phone: 503-391-7175