Provider Demographics
NPI:1245779354
Name:NORTHWEST YOUTH DISCOVERY
Entity Type:Organization
Organization Name:NORTHWEST YOUTH DISCOVERY
Other - Org Name:NORTHWEST DISCOVERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:STREETER
Authorized Official - Suffix:
Authorized Official - Credentials:MS, MED
Authorized Official - Phone:541-647-9609
Mailing Address - Street 1:70 SW CENTURY DR STE 100-118
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97702-3557
Mailing Address - Country:US
Mailing Address - Phone:541-647-9609
Mailing Address - Fax:
Practice Address - Street 1:361 NE FRANKLIN AVE BLDG E
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-4917
Practice Address - Country:US
Practice Address - Phone:541-241-3109
Practice Address - Fax:541-241-3109
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NORTHWEST YOUTH DISCOVERY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-02-22
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC3674101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty