Basic Information
| Provider Information | |||||||||
| NPI: | 1720126550 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COOLEY | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | LEN | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | BA, BAC, CADC1 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5695 KINGS VALLEY HWY | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973389437 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034209671 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3325 HAROLD DR NE | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973051339 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5033632021 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/02/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
ID Information
| ID | Type | State | Issuer | Description | 981004 | 01 | OR | ACCBO | OTHER |