Provider Demographics
NPI:1295857977
Name:POLK COUNTY MENTAL HEALTH
Entity Type:Organization
Organization Name:POLK COUNTY MENTAL HEALTH
Other - Org Name:POLK COUNTY MENTAL HEALTH ADDICTION SERVICES
Other - Org Type:Other Name
Authorized Official - Title/Position:ADDICTIONS COUNSELOR
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:KLEIN
Authorized Official - Suffix:
Authorized Official - Credentials:CADC-II QMHA BS
Authorized Official - Phone:503-623-9289
Mailing Address - Street 1:557 21ST ST SE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-6526
Mailing Address - Country:US
Mailing Address - Phone:503-991-0226
Mailing Address - Fax:
Practice Address - Street 1:557 21ST ST SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-6526
Practice Address - Country:US
Practice Address - Phone:503-991-0226
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-04
Last Update Date:2008-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR04-R-19101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR04-R-19OtherCADC-II ID NUMBER