Healthcare Provider Details

I. General information

NPI: 1104109677
Provider Name (Legal Business Name): PROVIDENCE HEALTH & SERVICES - OREGON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/21/2011
Last Update Date: 05/14/2025
Certification Date: 05/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3101 SE 192ND AVE SUITE 104
VANCOUVER WA
98683-1442
US

IV. Provider business mailing address

PO BOX 3395
PORTLAND OR
97208-3395
US

V. Phone/Fax

Practice location:
  • Phone: 360-553-7480
  • Fax: 360-553-7485
Mailing address:
  • Phone: 503-215-4323
  • Fax: 503-215-0297

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number StateWI
# 3
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number StateWA

VIII. Authorized Official

Name: DONALD W ANDERSON JR.
Title or Position: ASSISTANT SECRETARY ENROLLMENTS
Credential:
Phone: 425-358-9786