Basic Information
Provider Information | |||||||||
NPI: | 1538572177 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BAILEY | ||||||||
FirstName: | HEATHER | ||||||||
MiddleName: | JO | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | LCSW | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | CULP | ||||||||
OtherFirstName: | HEATHER | ||||||||
OtherMiddleName: | JO | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1115 SE 164TH AVE DEPT 358 | ||||||||
Address2: |   | ||||||||
City: | VANCOUVER | ||||||||
State: | WA | ||||||||
PostalCode: | 986838004 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3607291412 | ||||||||
FaxNumber: | 3607293025 | ||||||||
Practice Location | |||||||||
Address1: | 530 9TH ST | ||||||||
Address2: |   | ||||||||
City: | FLORENCE | ||||||||
State: | OR | ||||||||
PostalCode: | 974397388 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5419977134 | ||||||||
FaxNumber: | 5419971336 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/10/2014 | ||||||||
LastUpdateDate: | 07/27/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/27/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | LMSW-33914 | ID | N |   | Behavioral Health & Social Service Providers | Social Worker |   | 1041C0700X | L8135 | OR | Y |   | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.