Basic Information
| Provider Information | |||||||||
| NPI: | 1851784045 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | COVER | ||||||||
| FirstName: | JOSEPH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3325 HAROLD DR NE | ||||||||
| Address2: | PO BOX 17818 | ||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973051339 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5033632021 | ||||||||
| FaxNumber: | 5033634820 | ||||||||
| Practice Location | |||||||||
| Address1: | 3325 HAROLD DR NE | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973051339 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5033632021 | ||||||||
| FaxNumber: | 5033634820 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/11/2015 | ||||||||
| LastUpdateDate: | 03/11/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | OR | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 26-3634042 | 05 | OR | MEDICAID |