=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295857977
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | POLK COUNTY MENTAL HEALTH
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/04/2007
-----------------------------------------------------
Last Update Date | 08/14/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 557 21ST ST SE
-----------------------------------------------------
City | SALEM
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97301-6526
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-991-0226
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 557 21ST ST SE
-----------------------------------------------------
City | SALEM
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97301-6526
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-991-0226
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADDICTIONS COUNSELOR
-----------------------------------------------------
Name | SUSAN MARIE KLEIN
-----------------------------------------------------
Credential | CADC-II QMHA BS
-----------------------------------------------------
Telephone | 503-623-9289
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | 04-R-19
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------