Basic Information
Provider Information | |||||||||
NPI: | 1366656068 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | DESCHUTES COUNTY OREGON | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | DESCHUTES COUNTY HEALTH SERVICES | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2577 NE COURTNEY DRIVE | ||||||||
Address2: |   | ||||||||
City: | BEND | ||||||||
State: | OR | ||||||||
PostalCode: | 977017638 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5413227500 | ||||||||
FaxNumber: | 5413227565 | ||||||||
Practice Location | |||||||||
Address1: | 2577 NE COURTNEY DRIVE | ||||||||
Address2: |   | ||||||||
City: | BEND | ||||||||
State: | OR | ||||||||
PostalCode: | 977017638 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5413227500 | ||||||||
FaxNumber: | 5413227565 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/10/2007 | ||||||||
LastUpdateDate: | 02/10/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | SMILIE | ||||||||
AuthorizedOfficialFirstName: | JANE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 5413227500 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X |   | OR | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
ID | Type | State | Issuer | Description | 184176 | 05 | OR |   | MEDICAID |