Provider Demographics
NPI:1629780572
Name:ANDERSON, TIMOTHY WAYNE (CRM, THW)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:WAYNE
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:CRM, THW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9600 HEBO RD
Mailing Address - Street 2:
Mailing Address - City:GRAND RONDE
Mailing Address - State:OR
Mailing Address - Zip Code:97347-9704
Mailing Address - Country:US
Mailing Address - Phone:971-387-6846
Mailing Address - Fax:
Practice Address - Street 1:1011 COMMERCIAL ST NE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-1049
Practice Address - Country:US
Practice Address - Phone:503-983-9900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-21
Last Update Date:2022-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)