Basic Information
| Provider Information | |||||||||
| NPI: | 1144612599 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HART | ||||||||
| FirstName: | RYUSHIN | ||||||||
| MiddleName: | |||||||||
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| Credential: | MSW, CSWA, CADC I | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 579 | ||||||||
| Address2: | |||||||||
| City: | CORVALLIS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973390579 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417666835 | ||||||||
| FaxNumber: | 5417666164 | ||||||||
| Practice Location | |||||||||
| Address1: | 530 NW 27TH ST | ||||||||
| Address2: | |||||||||
| City: | CORVALLIS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973305223 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417666835 | ||||||||
| FaxNumber: | 5417666164 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/23/2015 | ||||||||
| LastUpdateDate: | 05/10/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 05/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 18-10-06 | OR | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 104100000X | Y | Behavioral Health & Social Service Providers | Social Worker |
ID Information
| ID | Type | State | Issuer | Description | 500744748 | 05 | OR | MEDICAID |