Provider Demographics
NPI:1417495862
Name:IMPACT NW
Entity Type:Organization
Organization Name:IMPACT NW
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LTK PROJECT COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:ADAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-227-8888
Mailing Address - Street 1:PO BOX 33530
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97292-3530
Mailing Address - Country:US
Mailing Address - Phone:503-294-7400
Mailing Address - Fax:503-802-0046
Practice Address - Street 1:7211 SE 62ND AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97206-7564
Practice Address - Country:US
Practice Address - Phone:503-489-7034
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-06
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251B00000XAgenciesCase ManagementGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500721499Medicaid