Basic Information
| Provider Information | |||||||||
| NPI: | 1376963421 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SANTIAM CORRECTIONAL INSTITURE | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | TURNING POINT PROGRAM | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 847 NE 19TH AVE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972322684 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032380769 | ||||||||
| FaxNumber: | 5039637711 | ||||||||
| Practice Location | |||||||||
| Address1: | 847 NE 19TH AVE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972322684 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032380769 | ||||||||
| FaxNumber: | 5039637711 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/16/2014 | ||||||||
| LastUpdateDate: | 04/16/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WALKER | ||||||||
| AuthorizedOfficialFirstName: | DERALD | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT / CEO | ||||||||
| AuthorizedOfficialTelephone: | 5032380769 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CASCADIA BEHAVIORAL HELATHCARE, INC. | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | PHD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
No ID Information.