Basic Information
| Provider Information | |||||||||
| NPI: | 1629698576 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOX | ||||||||
| FirstName: | ANNA | ||||||||
| MiddleName: | CECELIA | ||||||||
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| Credential: | RN/QMHP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3587 HEATHROW WAY | ||||||||
| Address2: | |||||||||
| City: | MEDFORD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975044004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5418588170 | ||||||||
| FaxNumber: | 5418588167 | ||||||||
| Practice Location | |||||||||
| Address1: | 17640 NE HALSEY ST | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972306733 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034895045 | ||||||||
| FaxNumber: | 5034895638 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/21/2020 | ||||||||
| LastUpdateDate: | 04/21/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/21/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 163WP0808X | 202001487RN | OR | Y | Nursing Service Providers | Registered Nurse | Psych/Mental Health |
No ID Information.