Basic Information
| Provider Information | |||||||||
| NPI: | 1942349147 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CASCADIA BEHAVIORAL HEALTHCARE INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | COLUMBIA RIVER CORRECTIONAL FACILITY | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 8459 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972078459 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032380769 | ||||||||
| FaxNumber: | 5035526208 | ||||||||
| Practice Location | |||||||||
| Address1: | 9111 NE SUNDERLAND RD | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972111708 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032806646 | ||||||||
| FaxNumber: | 5032806081 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/05/2007 | ||||||||
| LastUpdateDate: | 06/12/2008 | ||||||||
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| AuthorizedOfficialLastName: | SAMA | ||||||||
| AuthorizedOfficialFirstName: | ENRIQUE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VP, HUMAN RESOURCES | ||||||||
| AuthorizedOfficialTelephone: | 5039637791 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CASCADIA BEHAVIORAL HEALTHCARE INC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
ID Information
| ID | Type | State | Issuer | Description | 226398 | 05 | OR | MEDICAID | 223347 | 05 | OR | MEDICAID |