Basic Information
| Provider Information | |||||||||
| NPI: | 1508090994 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HAZELWOOD HOUSE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5415 SW WESTGATE DR | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972212409 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5036453581 | ||||||||
| FaxNumber: | 5036298517 | ||||||||
| Practice Location | |||||||||
| Address1: | 5415 SW WESTGATE DR | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972212409 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5036453581 | ||||||||
| FaxNumber: | 5036298517 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/13/2009 | ||||||||
| LastUpdateDate: | 03/09/2022 | ||||||||
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| AuthorizedOfficialLastName: | MONNAT | ||||||||
| AuthorizedOfficialFirstName: | MARY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO | ||||||||
| AuthorizedOfficialTelephone: | 5036453581 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | LIFEWORKS NORTHWEST | ||||||||
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| NPICertificationDate: | 03/09/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 320800000X | Y | Residential Treatment Facilities | Community Based Residential Treatment Facility, Mental Illness |
ID Information
| ID | Type | State | Issuer | Description | 512881 | 05 | OR | MEDICAID |