Provider Demographics
NPI:1467823112
Name:AMEZOLA, SALVADOR (CADC II)
Entity Type:Individual
Prefix:
First Name:SALVADOR
Middle Name:
Last Name:AMEZOLA
Suffix:
Gender:M
Credentials:CADC II
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:236 SE D ST
Mailing Address - Street 2:
Mailing Address - City:MADRAS
Mailing Address - State:OR
Mailing Address - Zip Code:97741-1619
Mailing Address - Country:US
Mailing Address - Phone:541-475-5300
Mailing Address - Fax:540-504-1195
Practice Address - Street 1:340 NW 5TH ST
Practice Address - Street 2:BOX 1710
Practice Address - City:REDMOND
Practice Address - State:OR
Practice Address - Zip Code:97756-1869
Practice Address - Country:US
Practice Address - Phone:541-516-4087
Practice Address - Fax:541-504-1195
Is Sole Proprietor?:No
Enumeration Date:2015-10-07
Last Update Date:2015-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR02 P 03101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)