Basic Information
| Provider Information | |||||||||
| NPI: | 1245378546 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FORA HEALTH INC. | ||||||||
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| OtherOrganizationName: | DE PAUL TREATMENT CENTERS, INC. | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | P.O.BOX 16040 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97292 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5035351150 | ||||||||
| FaxNumber: | 5035351190 | ||||||||
| Practice Location | |||||||||
| Address1: | 10230 SE CHERRY BLOSSOM DR | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5035351150 | ||||||||
| FaxNumber: | 5035351190 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/01/2007 | ||||||||
| LastUpdateDate: | 07/27/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | JOHNSON | ||||||||
| AuthorizedOfficialFirstName: | MALLORY | ||||||||
| AuthorizedOfficialMiddleName: | JUANITA-ANN | ||||||||
| AuthorizedOfficialTitleorPosition: | CONTRACT COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 5035351156 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 07/27/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0405X | OR | N | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder | 320800000X | OR | N | Residential Treatment Facilities | Community Based Residential Treatment Facility, Mental Illness | 324500000X | OR | N | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility | 3245S0500X | OR | N | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility | Substance Abuse Treatment, Children | 101YA0400X | OR | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YM0800X | OR | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health | 261QM0850X | OR | N | Ambulatory Health Care Facilities | Clinic/Center | Adult Mental Health | 261QR0401X | OR | N | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Comprehensive Outpatient Rehabilitation Facility (CORF) | 261QM0801X | OR | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | 299811 | 05 | OR | MEDICAID |