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General NPI Number Information
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NPI Number | 1720013071
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Entity Type | Organization
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Legal Business Name | POLK COUNTY ALCOHOL AND DRUG
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Dates
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Enumeration Date | 07/12/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 182 SW ACADEMY SUITE #304
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City | DALLAS
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State | OR
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Zip | 97338-1922
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Country | US
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Telephone | 503-623-9289
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Fax | 503-831-1726
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Provider Business Mailing Address
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Address Line | 182 SW ACADEMY ST SUITE #310 POLK COUNTY ALCOHOL AND DRUG
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City | DALLAS
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State | OR
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Zip | 97338-1922
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Country | US
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Telephone | 503-623-9317
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Fax | 503-623-2731
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Authorized Official
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Title or Position | POLK COUNTY ADMINISTRATIVE OFFICER
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Name | MR. GREG P HANSEN
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Credential |
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Telephone | 503-623-8173
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | CERTIFICATE OF APPRO
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License Number State | OR
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