Basic Information
| Provider Information | |||||||||
| NPI: | 1316123326 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TRILLIUM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4455 NE HIGHWAY 20 | ||||||||
| Address2: | |||||||||
| City: | CORVALLIS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973309695 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417585944 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4455 NE HIGHWAY 20 | ||||||||
| Address2: | |||||||||
| City: | CORVALLIS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973309695 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417585944 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/21/2008 | ||||||||
| LastUpdateDate: | 01/21/2008 | ||||||||
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| AuthorizedOfficialLastName: | SWEENEY | ||||||||
| AuthorizedOfficialFirstName: | JOSHUA | ||||||||
| AuthorizedOfficialMiddleName: | LENNON | ||||||||
| AuthorizedOfficialTitleorPosition: | CATS1 | ||||||||
| AuthorizedOfficialTelephone: | 5417585944 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 323P00000X | Y | Residential Treatment Facilities | Psychiatric Residential Treatment Facility |
No ID Information.