Provider Demographics
NPI:1629848106
Name:RETASKET, GRAHAM NELSON
Entity Type:Individual
Prefix:MR
First Name:GRAHAM
Middle Name:NELSON
Last Name:RETASKET
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 SE GOODNIGHT AVE UNIT 29
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97333-2191
Mailing Address - Country:US
Mailing Address - Phone:503-975-1476
Mailing Address - Fax:
Practice Address - Street 1:182 SW ACADEMY ST
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:OR
Practice Address - Zip Code:97338-1996
Practice Address - Country:US
Practice Address - Phone:503-962-3928
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-04
Last Update Date:2024-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)