Provider Demographics
NPI:1144612599
Name:HART, RYUSHIN (MSW, CSWA, CADC I)
Entity Type:Individual
Prefix:
First Name:RYUSHIN
Middle Name:
Last Name:HART
Suffix:
Gender:M
Credentials:MSW, CSWA, CADC I
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 579
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97339-0579
Mailing Address - Country:US
Mailing Address - Phone:541-766-6835
Mailing Address - Fax:541-766-6164
Practice Address - Street 1:530 NW 27TH ST
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97330-5223
Practice Address - Country:US
Practice Address - Phone:541-766-6835
Practice Address - Fax:541-766-6164
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-23
Last Update Date:2020-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR18-10-06101YA0400X
104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500744748Medicaid