Basic Information
| Provider Information | |||||||||
| NPI: | 1841318581 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DEPAUL YOUTH AND FAMILY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4310 NE KILLINGSWORTH ST | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972181404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5035351150 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4310 NE KILLINGSWORTH ST | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972181404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5035351150 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/27/2007 | ||||||||
| LastUpdateDate: | 08/08/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ALDRICH | ||||||||
| AuthorizedOfficialFirstName: | SHANAKO | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | GIRLS PROGRAM SUPERVISIOR | ||||||||
| AuthorizedOfficialTelephone: | 5035351150 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MISS | ||||||||
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| AuthorizedOfficialCredential: | CADCI QMHA | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3245S0500X | Y | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility | Substance Abuse Treatment, Children |
No ID Information.