Healthcare Provider Details

I. General information

NPI: 1013952829
Provider Name (Legal Business Name): OLALLA CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/17/2006
Last Update Date: 04/24/2020
Certification Date: 04/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

321 SE 3RD ST
TOLEDO OR
97391-1613
US

IV. Provider business mailing address

321 SE 3RD ST
TOLEDO OR
97391-1613
US

V. Phone/Fax

Practice location:
  • Phone: 541-336-2254
  • Fax: 541-336-1803
Mailing address:
  • Phone: 541-336-2254
  • Fax: 541-336-1803

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number106
License Number StateOR

VIII. Authorized Official

Name: DAKOTA SIERRA MCKNIGHT-TODD
Title or Position: OFFICE MANAGER
Credential:
Phone: 541-336-2254