Provider Demographics
NPI:1659758167
Name:ADAGIO THERAPY CENTER, LLC
Entity Type:Organization
Organization Name:ADAGIO THERAPY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MARTHA
Authorized Official - Middle Name:
Authorized Official - Last Name:WANG
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:818-253-9264
Mailing Address - Street 1:388 STATE ST
Mailing Address - Street 2:SUITE 707
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-3866
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:388 STATE ST
Practice Address - Street 2:SUITE 707
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-3866
Practice Address - Country:US
Practice Address - Phone:818-253-9264
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-05
Last Update Date:2015-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2518103TC0700X
ORL61131041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty