Provider Demographics
NPI:1619208337
Name:DECKER, DERWIN (CADC 1)
Entity Type:Individual
Prefix:
First Name:DERWIN
Middle Name:
Last Name:DECKER
Suffix:
Gender:M
Credentials:CADC 1
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3949 SOUTH 6TH STREET
Mailing Address - Street 2:
Mailing Address - City:KLAMATH FALLS
Mailing Address - State:OR
Mailing Address - Zip Code:97603-4746
Mailing Address - Country:US
Mailing Address - Phone:541-882-1487
Mailing Address - Fax:541-882-1670
Practice Address - Street 1:3949 SOUTH 6TH STREET
Practice Address - Street 2:
Practice Address - City:KLAMATH FALLS
Practice Address - State:OR
Practice Address - Zip Code:97603-4746
Practice Address - Country:US
Practice Address - Phone:541-882-1487
Practice Address - Fax:541-882-1670
Is Sole Proprietor?:No
Enumeration Date:2010-01-20
Last Update Date:2010-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR95-04-35101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR129861Medicaid