Provider Demographics
NPI:1275120396
Name:JAMES, EDWARD C
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:C
Last Name:JAMES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9115 SOUTHWEST OLESON RD. STE. 100
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97223-6876
Mailing Address - Country:US
Mailing Address - Phone:971-239-6653
Mailing Address - Fax:
Practice Address - Street 1:4962 LIBERTY RD S APT 65
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97306-2427
Practice Address - Country:US
Practice Address - Phone:971-239-6653
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-22
Last Update Date:2021-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORBACB626543106S00000X
ORABA-IN-10213207106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician