Provider Demographics
NPI:1457477333
Name:POLK COUNTY MENTAL HEALTH
Entity Type:Organization
Organization Name:POLK COUNTY MENTAL HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SUPERVISOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:MANITSAS
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:503-623-9289
Mailing Address - Street 1:182 SW ACADEMY ST
Mailing Address - Street 2:SUITE 304
Mailing Address - City:DALLAS
Mailing Address - State:OR
Mailing Address - Zip Code:97338-1922
Mailing Address - Country:US
Mailing Address - Phone:503-623-9289
Mailing Address - Fax:503-831-1726
Practice Address - Street 1:182 SW ACADEMY ST
Practice Address - Street 2:SUITE 304
Practice Address - City:DALLAS
Practice Address - State:OR
Practice Address - Zip Code:97338-1922
Practice Address - Country:US
Practice Address - Phone:503-623-9289
Practice Address - Fax:503-831-1726
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health