Provider Demographics
NPI:1558061028
Name:CHURCH AT THE PARK
Entity Type:Organization
Organization Name:CHURCH AT THE PARK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF CLINICAL OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:SEAN
Authorized Official - Middle Name:E
Authorized Official - Last Name:ROBERTSON
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:503-459-7685
Mailing Address - Street 1:2111 FRONT ST NE STE 1-103
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-0779
Mailing Address - Country:US
Mailing Address - Phone:503-459-7685
Mailing Address - Fax:
Practice Address - Street 1:1280 CENTER ST NE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-4113
Practice Address - Country:US
Practice Address - Phone:503-507-4992
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-03
Last Update Date:2023-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282J00000XHospitalsReligious Nonmedical Health Care Institution
No251B00000XAgenciesCase Management
No251S00000XAgenciesCommunity/Behavioral Health