Provider Demographics
NPI:1356322713
Name:TAHANA WHITECROW FOUNDATION
Entity Type:Organization
Organization Name:TAHANA WHITECROW FOUNDATION
Other - Org Name:TAHANA WHITECROW OUTPATIENT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR SUBSTANCE ABUSE COUNSELOR
Authorized Official - Prefix:MS
Authorized Official - First Name:MELANIE
Authorized Official - Middle Name:MAE
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:CADCII NCACI
Authorized Official - Phone:503-585-0564
Mailing Address - Street 1:2350 WALLACE RD NW
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97304-2127
Mailing Address - Country:US
Mailing Address - Phone:503-585-0564
Mailing Address - Fax:503-585-3302
Practice Address - Street 1:2350 WALLACE RD NW
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97304-2127
Practice Address - Country:US
Practice Address - Phone:503-585-0564
Practice Address - Fax:503-585-3302
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR132832Medicaid