Provider Demographics
NPI:1790234078
Name:SPADE, DANA (MA, LPC)
Entity Type:Individual
Prefix:
First Name:DANA
Middle Name:
Last Name:SPADE
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 100
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:OR
Mailing Address - Zip Code:97321-0031
Mailing Address - Country:US
Mailing Address - Phone:541-967-3819
Mailing Address - Fax:541-967-7259
Practice Address - Street 1:104 4TH AVE SW
Practice Address - Street 2:ROOM 238
Practice Address - City:ALBANY
Practice Address - State:OR
Practice Address - Zip Code:97321-2804
Practice Address - Country:US
Practice Address - Phone:541-967-3819
Practice Address - Fax:541-967-7259
Is Sole Proprietor?:No
Enumeration Date:2016-09-27
Last Update Date:2020-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC5657101YP2500X
101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR101279Medicaid